Ryan White Programming that primarily supports clinical care falls short when core people needs are not met: Further evidence from the Medical Monitoring Project

In the paper by Dasgupta et al., the authors examine the unmet needs for ancillary services for people living with HIV (PLWH). These services were categorized as HIV clinical support services (ie. medication coverage), other medical services (ie. dental) or subsistence services (ie. food). The authors utilize information from the 2017–2019 cycles of the CDC Medical Monitoring Project (MMP) and then explore how unmet needs vary by insurance type and Ryan White HIV/AIDS Program (RWHAP) participation. As would be expected, nearly half of PLWH reported having at least one ancillary care need and those uninsured experienced high levels (58.7%) of at least one unmet need. In addition, unmet need for subsistence services were not improved by RWHAP participation among those uninsured or those with any health care coverage.

Profound social and economic barriers often prevent PLWH from deriving full benefit from efficacious biomedical interventions.^1,2 Efforts to interrupt transmission routinely focus on (re)connecting patients to health systems that they are not currently engaging, for testing and PrEP/ART uptake and adherence. Some innovative approaches seek to use public health surveillance data or clinic-based patient retracing, as the authors suggest. Unfortunately, such strategies have demonstrated minimal effect on viral suppression when tested in controlled trials.^3–5 When PLWH care engagement interventions have been successful^6,7 and other mobile/virtual interventions,⁸ they often miss those with significant economic and social disadvantage. Those with these disadvantages include PLWH who are without social support, have sporadic internet or phone access or ability to engage in resource counseling.⁹ Maslow Hierarchy’s of Needs outlines overlapping barriers and needs (housing, employment, food) that are drivers of lack of care entry and/or care disengagement.^10–13 These are precisely the needs outlined by the authors as subsistence needs. Prior research actually finds lower engagement among Medicaid beneficiaries than among uncovered Ryan White HIV/AIDS Program (RWHAP)-supported PLWH.^14,15 However, evidence suggests that variation in viral suppression persists after transitions between RWHAP-supported coverage, Medicaid, and private insurances. Such patterns suggest that variations likely arise from socioeconomic rather than program factors.^15,16 Economic hardship (i.e., living at or below the poverty line) is one of several risk factors that contribute to HIV transmission and non-uptake of PrEP, followed by housing instability and employment.^11,17,18 Health decisions, such as ART and PrEP uptake and persistence, are often pushed to the side in favor of developing economic survival techniques around housing and/or food insecurity. Previous work has found, for example, that food security is linked to incomplete viral suppression. ^19,20 Without addressing foundational needs, downstream care continuum outcomes will continue to be negatively impacted.

Engaging community members first around financial well-being has the potential to impact downstream care continua outcomes. Communities of color in the US have been persistently economically disadvantaged due to longstanding practices of structural, institutional, and individual racism and discrimination.^21,22 Collectively, these mechanisms of social, economic and political exclusion and disadvantage produce and deepen severe health disparities.^6,23–25 Unemployment rates among Black adults are 2 times that of White adults, a factor that is also evident among sexual minority men.³⁰ Furthermore, ethnoracial disparities in employment and layoffs have worsened during the COVID-19 pandemic.^31,32 For sexual minority men of color living with HIV, these disadvantages deepen health inequities and exacerbate the risk of falling out of integrated care continua.³³ Several studies have documented that PLWH who have greater social and economic support (e.g. stable housing, employment, and positive peer relationships) report higher rates of engagement, including testing and less unrecognized HIV infections.^34–37 Other examples leading with foundational needs exist, such as HPTN 073, a social work intervention that prioritized resource counseling for foundational needs over PrEP linkage in order to impact downstream PrEP engagement.³⁸ More recently, we used a Flipping the Script approach to engage clients in COVID-19 contact tracing whereby subsistence resources, i.e., cash transfers, employment support and health insurance, were initiated prior to asking about recent close contacts.^39,40 While ‘resources first’ is an intuitive approach, operationalization and attention to specific intervention agents and ingredients have not been systematically explored within rigorous implementation science frameworks. Yet such supports are pivotal for ensuring equitable and sustained access, uptake, and retention in treatment modalities necessary to achieve Getting to Zero’s goal of no new infections by 2030–2040.^41,42

Existing Ryan White Case Management (CM) models, which could address core needs, are hampered by several factors, including limitations in amounts that can be allocated to subsistence needs.^43,44 Innovation and attention is needed to support the HIV care workforce. Ryan White case managers and other social service professionals, for example, working with PLWH experience frequent burnout (e.g. emotional exhaustion, reduced professional accomplishment, and apathetic tendencies towards clients and coworkers).^45–47 Intense client and administrative demands also lead to higher stress environments, which can hinder CMs’ abilities to provide effective supportive services.⁴⁵ Maintaining professional boundaries can become especially difficult when clients are experiencing crises, or when CMs enter unfamiliar spaces or are taking work-related calls/request late into the evening.^45,48,49 These boundary challenges are often exacerbated by lack of quality supervision, poor support from the larger team, and an ever-increasing caseload with limited resources.^45,50 Administrative workload for social service and healthcare workers has increased over the years, which may limit time with clients to address barriers to care continua engagement.^45,47,48,51 Of particular relevance, Ginossar et al.⁴⁹ examined HIV provider burnout and found that organizational culture (i.e., inter-team collaboration) directly impacted burnout, while effective communication reduced emotional exhaustion. In addition, Garner et al.⁵² found that providing staff with training, coaching and technical assistance was associated with improved implementation and intervention effectiveness in a hybrid type 2 trial of a substance use intervention for PLWH. These studies highlight the importance of organizational investments and implementation strategies for supporting the HIV workforce, a current gap in the extant research.^53–55 Successful interventions should intensify existing case management resource support systems, which has the potential to not only impact the lives and care continua of PLWH, but also to fulfill an ending the epidemic priority of revitalizing and sustaining the HIV frontline workforce.