Engaging the invisible: Locating and linking the long-term, out-of-care PLWH - a community systems approach

Background: The U.S. prioritizes locating over 650,000 PLWH that are not in care, and linking them to HIV services as a critical strategy in ending the pandemic. Yet little is known about local realities that keep PLWH out of care or what is needed to mobilize and coordinate a system of care providers. Methods: Bay Area Network for Positive Health (BANPH) is a consortium of 12 agencies/HIV clinics in San Francisco and Oakland that identifies individuals not in HIV care and links them. Using mixed-methodologies, we illustrate the individual-level and systems-level requirements to effectively engage the most disenfranchised. PLWH are identified through street outreach, syringe exchange, jails, prison, support groups, and review of clinic records. Individuals complete a survey to assess barriers/needs, and are linked to HIV care and auxiliary services. Network agencies share resources, lend peer-support, and problem-solve together to increase effective outreach, linkage and retention in HIV care. Results: Over 500 PLWH have been engaged by BANPH. Most are over age 40 (62%), 58% male, and primarily African American and Latino (73%). It took an average of 56 days from first contact to medical appointment. Individuals knew their status on average for 10 years. 25% reported avoiding treatment because someone might find out about their HIV. BANPH agencies increased their own capacity in outreach, data collection, and collaboration. Conclusions: Creating an urban collaborative network built with mutual respect and a common mission has proven to be an effective approach to systems change and effective engagement of disenfranchised PLWH.