From HIV to Coronavirus: AIDS Service Organizations Adaptative Responses to COVID-19, Birmingham, Alabama

AIDS Service Organizations (ASOs) are, by definition, adept at dealing with pandemics and the political and social challenges that inevitably follow. When HIV/AIDS first became a major public health concern in the United States in the 1980s, ASOs were established to provide HIV testing and social services to people living with HIV (PLWH) and their families. Over the years, ASOs have needed to be creative to meet the needs of our clients when faced with ongoing challenges like HIV stigma, limited funding streams, and political inertia. Yet, in the nearly 40 years since the CDC published its June 5, 1981 issue of its Morbidity and Mortality Weekly Report on a mysterious disease that would later be known as AIDS [1], ASOs have never had to respond to a pandemic that rivaled the scope and intensity of HIV. This changed on March 11, 2020 when the World Health Organization (WHO) first declared SARS‐CoV‐2 (novel coronavirus disease 2019, or “COVID-19”) a pandemic [2]. As the WHO Director-General stated, this pandemic declaration was motivated, in part, by the “alarming levels of inaction” [2].

While it is true that inaction has framed much of the US response to COVID-19, the same cannot be said for the healthcare sector, including ASOs, who have had to rapidly and creatively adapt to COVID-19 in order to continue to meet the needs of our clients. One ASO that quickly responded to COVID-19 is Birmingham AIDS Outreach (BAO), first established in 1985 as Alabama’s first ASO, and a primary provider of social services for PLWH in the Birmingham, AL area. Deemed an “essential” organization under guidance from the US Department of Health and Human Services Health Resources and Services Administration, BAO has remained continuously open even after the Alabama State Governor ordered closure of all non-essential businesses on March 27, 2020 in response to the COVID-19 outbreak [3]. Since March 16, 2020, BAO has continued to keep its doors open and programs running in creative ways, even receiving attention for its adaptability and continued service to the community from a local news organization [4]. These adaptations, while specific to BAO, may provide guidance for other ASOs during the COVID-19 crisis.

Except for its walk-in HIV and STI testing and community outreach events, all other BAO programs and services have remained open to serve current clients. BAO’s counseling services, legal services, and HIV and LGBTQ support group meetings have been conducted either through telephone or secure videoconferencing. Paperwork is completed using email or over the phone, thereby eliminating any administrative need for in-person contact. Nutritional services, transportation vouchers, medical items, pet food, and personal care items are provided through curbside service, allowing clients to remain in their cars while BAO staff load any of the previously mentioned items into their vehicles. Case managers can complete any needed assessments over the phone and, if paperwork must be exchanged, a designated BAO employee is in charge of transferring paperwork from clients’ cars. This innovative curbside service allows clients to receive needed services while limiting physical interaction between BAO’s clients and staff.

During BAO’s first week of COVID-19-related operational changes, it provided 57 telehealth visits, 21 phone counseling sessions, 80 h of legal services, and 172 food and personal care boxes. In fact, client demand for some services has actually increased following BAO’s implementation of new operational procedures on March 16. Between March 1 and March 15, BAO provided a total of 1716 nutritional service items (including food boxes, food vouchers, nutritional supplements, and personal care items such as shampoo, soap, and razors) for 346 clients; from March 16 to March 31, this increased to 1778 nutritional services for 354 clients. The number of counseling services has increased, as well. During February 2020, BAO provided 76 counseling sessions and had 12 new clients initiate counseling services, while, in March 2020, BAO provided 110 counseling sessions and 16 new clients initiate counseling services. It is possible that this increase in counseling services is a result of the COVID-19 pandemic given that social isolation, a hallmark of the social distancing response required to slow the rate of new COVID-19 infections, has been linked to an increase in negative mental health outcomes such decreased wellbeing [5] and increased depression [6, 7] and anxiety [7]. Employment disruption may also have a negative impact on mental health. Research conducted in China in January and February 2020 found that people who stopped working due to the COVID-19 outbreak were more likely to experience poorer mental health than people who kept working, regardless of whether they worked at home or at their place of employment [8].

While COVID-19 has presented many challenges, some of BAO’s programmatic changes may persist or even become status-quo once normal business operations resume. The legal services department is currently working to implement a curbside estate planning service that clients can access when they come to pick up food boxes or access other services currently operating at curbside. BAO attorneys hope that the uncertainty surrounding COVID-19 will help motivate more clients to prepare legal documents such as advance directives and wills, and that this momentum will be sustained even after normal operations recommence. Counseling staff are already discussing the merits of tele-counseling as an important service to maintain for clients who are unable to attend face-to-face counseling visits or who prefer to attend sessions remotely. BAO has also implemented popular “shelter-in-place” support groups that offer “distant socializing” for LGBTQ youth. These online social groups are facilitated by BAO’s licensed therapists and are held over Zoom, a free videoconferencing service, several times a week. Another positive impact of BAO’s operational changes is an increase in staff cross-training. Due to current cessation of community HIV testing and education events, prevention staff have temporarily been moved into client services. This operational change has not only prevented staff layoffs, but it also provided a valuable opportunity for prevention staff to expand their skillset. In addition, the increase in number of staff trained in client services has enabled BAO to reduce work schedules to allow employees to spend more days at home and reduce chance of exposure to COVID-19.

Though COVID-19 has swiftly and perhaps permanently altered some aspects of society, BAO and other ASOs, clinics, and healthcare organizations have and will continue to serve the needs of PLWH. Demand for essential services like food and personal care items will likely continue to grow as PLWH shelter-in-place and seek to avoid crowded areas like grocery stores. There will also likely be a continuing need for counseling services and virtual ways to connect and socialize with peers to combat the negative effects of social isolation. As the Joint United Nations Programme on HIV and AIDS report on “Rights in the time COVID-19” emphasizes, our response to COVID-19 should draw from some of the lessons learned from the AIDS epidemic; chief among these is the role of the community and the importance of addressing community concerns and needs at the local level [9]. Though the reach of COVID-19 is felt globally, the ways in which individual communities respond is equally, if not more, important. ASOs have always modeled community-based leadership, and the HIV sector’s response to COVID-19 may serve as an exemplar for pandemic crisis response.