Hennepin County Health Care for the Homeless PrEP Pilot

Hennepin County Public Health is the largest local public health department in Minnesota. Minneapolis, Minnesota's largest city, is located in Hennepin County. Hennepin County, the most populous in the state, comprises 22% (1,266,000/5,640,000) of Minnesota's population. The county is situated in the Minneapolis-St. Paul-Bloomington Metropolitan Statistical Area (MSA), which is comprised of 15 counties and has a population of 3,657,477 as of 2020. It is the second largest MSA in the upper Mid-West.

According to the 2020 census, Hennepin County's population is 66% White (Not Hispanic), 13% Black or African American, 7.6% Asian/Pacific Islander (API), 7.6% Latinx, 5.0% multi-racial, 0.6% American Indian, and 0.47% other. The greatest concentrations of Blacks (African American and African-born), Latinx, API, and men who have sex with men (MSM) in Minnesota reside in Hennepin County, and Minneapolis has the third largest urban population of American Indians in the U.S. An estimate of the MSM population in the MSA is not available, but an Emory University study estimates the MSM population in Hennepin County to be 8.5% of the male population. In addition, despite having 22% of the state's population, 51% of Minnesota's HIV cases are in Hennepin County, the center of Minnesota's HIV epidemic.  

Hennepin County Public Health is home to Health Care for the Homeless (HCH), a Federally Qualified Health Center, and the department administers the Ryan White HIV/AIDS Program Part A grant for the 13-county Minneapolis-St. Paul transitional grant area (MSP-TGA). Hennepin County Public Health's Red Door Clinic historically diagnoses 20-25% of Minnesota's annual HIV cases.

An HIV outbreak among people who inject drugs and/or experiencing unsheltered homelessness began in December 2018 in Hennepin and neighboring Ramsey (St. Paul) Counties. The objective of Hennepin County Public Health's Health Care for the Homeless project, which began in August 2020, was to implement a relationship based, extremely low-barrier 6-12 month pilot of pre-exposure prophylaxis (PrEP) care coordination for unsheltered people who inject drugs (PWID) in order to prevent the acquisition of HIV and to stop forward transmission of HIV. The scope of the project included prescribing PrEP to four patients at three months with the ability to expand to eight patients at six months. The objectives of this pilot project were met and 23 patients were prescribed PrEP. Six patients have remained on PrEP for at least six months. An additional outcome of the project is that the HIV status of individuals was ascertained as HIV testing is required before PrEP can be prescribed; in fact, one individual tested positive for HIV at their initial PrEP work up. Overall, HCH providers identified more than 100 patients interested in PrEP.

Hennepin County's Health Care for the Homeless team provided immediate care to those experiencing homelessness and at risk for acquiring HIV. Health Care for the Homeless works to decrease barriers to accessing health care by bringing critical services to the homeless population; the program's clinics are co-located in eight shelters, drop-in centers, and community-based facilities in Minneapolis where people experiencing homelessness go for emergency shelter and other services. The Health Care for the Homeless team also provides mobile outreach, interdisciplinary health services and care coordination at these sites and out in the community. The program's website is Clinics and services | Hennepin County.

The public health impact of this project is vast as the county and state continue to respond to one of the largest HIV outbreaks in the country. Stopping forward transmission of HIV is integral to ending the outbreak and ultimately the epidemic. Part of the success of this program is that it meets people where they are at and responds to the immediate needs of the unsheltered community. Health Care for the Homeless nurses and outreach specialists are able to provide treatment on the streets, in shelters, and in homeless encampments. By reaching people where they are at, providers can level the playing field and reduce disparities by giving access to a medication that many would not have been able to obtain on their own.

In February 2020, the MN Department of Health (MDH) announced an HIV outbreak among people who inject drugs (PWID) in Hennepin and Ramsey Counties. This ongoing outbreak, as defined by CDC surveillance cluster detection methodology, began in December 2018. HIV DNA molecular cluster analysis is in progress which may help further identify networks where HIV is spreading rapidly. As of December 27, 2021, there were 85 cases identified in this outbreak. The outbreak disproportionally affects individuals who are American Indian (26%, 22/85), and people who have experienced unsheltered homelessness (51%, 43/85). With increasing rates of homelessness in the MSP-TGA due to the COVID-19 pandemic and the related economic downturn, a significant proportion of the MSP-TGA's homeless population remains at high risk for HIV infection.

The emergence of large homeless encampments in the MSP-TGA during the summer of 2018 is correlated with the outbreak. The target population for this pilot project included all individuals experiencing homelessness who are injection drug users or sexual partners of injection drug users. Health Care for the Homeless has been one of the primary providers to respond to the care and prevention needs of those at risk and diagnosed people with HIV (PWH) living in encampments where many of the outbreak cases were identified or linked. While Health Care for the Homeless is contracted to provide medical case management, they are also doing HIV testing and informing those tested of their status, providing referrals and harm reduction services, linking newly diagnosed PWH to care, and providing HIV medical care in the field including blood draws for CD4 counts and viral load tests, and antiretroviral (ART) dispensation. In addition, they began offering PrEP in August of 2020.

Homeless populations are among the most vulnerable in our society, with vast disparities evident when compared to stably housed individuals. Due to the COVID-19 pandemic and related economic downturn, Hennepin County has seen an increase in people experiencing homelessness. In addition to the lack of safe, affordable, desirable housing, the COVID-19 pandemic has complicated the efforts of public health departments to provide effective harm reduction services, including syringe exchange services, and to effectively test individuals at risk of HIV infection in unsheltered homeless settings.

Disease investigators determined that persons likely to be at higher risk include sex partners or syringe-sharing partners of outbreak related cases, people who inject drugs and their sex partners and needle/equipment sharing partners, and persons who exchange sex for income or other items they need. New cases continue to be identified. This population presents significant challenges in providing HIV medical care and supportive services needed to advance newly diagnosed individuals along the HIV care continuum, in turn preventing new HIV infections and ending the outbreak. This outbreak has most disproportionally affected individuals who are American Indian who represent 26% of HIV outbreak cases while only being 0.5% of the MSP-TGA total population. With street outreach and immediate care offered by the HCH team, health inequities have been reduced for homeless populations in Hennepin County.

Pre-exposure prophylaxis is an evidence-based high impact biomedical HIV prevention intervention recommended by the CDC¹, and is a US Preventive Services Task Force Grade A recommendation². The traditional clinic-based approach to providing PrEP to people at risk of acquiring HIV infection is unlikely to reach people who are experiencing unsheltered homelessness, especially those whose substance use disorder may pose additional challenges to receiving consistent preventive and follow up medical care. This current practice of PrEP delivery in the field by HCH outreach nurse providers is preferrable over the former practice of providing PrEP and care services exclusively in physical clinic settings because unsheltered homeless individuals now have access to a medication like PrEP that they would have struggled to access previously. Without street outreach, an individual would have to find a doctor who prescribed PrEP, make an appointment, determine how to pay for the appointment without insurance, and pay for the medications. Furthermore, many people experiencing homelessness feel unwelcomed in traditional medical settings and mistrust the healthcare system.  Access to PrEP is now offered on the street in a relationship based, low-barrier care model, without the added barriers of a facility-based appointment or cost. Within this outreach care model, PrEP is a real and innovative tool in fighting HIV transmission among unsheltered homeless populations.

¹US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update, A Clinical Practice Guideline, 2021

²Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis. U.S. Preventive Services Task Force, 2019.

The overall goal of this project was to facilitate use of PrEP by people who inject drugs and are experiencing unsheltered homelessness to prevent HIV acquisition in environments that are conducive to HIV cluster outbreaks. The objectives included: 1) implement a 6-12 month pilot of PrEP care coordination for unsheltered people who inject drugs (PWID) in order to prevent the acquisition of HIV; 2) provide PrEP to four patients at three months with the ability to expand to eight patients at six months; and 3) expand the project based on the success of the pilot, staff capacity, and community need.

The objectives were achieved by shoring up bandwidth of staff and coordinating with HCH resources and community partners. Health Care for the Homeless outreach nursing staff for this PrEP project included 1.0 FTE RN and 0.3 FTE NP. Health Care for the Homeless nurses worked with chemical health counselors, mental health counselors, providers with experience with psychiatric medications and medication assisted therapy (MAT) for opioid addiction, internal pharmacy consultants, and insurance assistance navigators. Each role was vital in delivering whole health services to homeless individuals. Rather than just focus on PrEP, the HCH care team was able to deliver multiple services to an individual. This whole health approach was one factor in the success of the pilot.

In addition to the above resources, HCH worked with community partners to ensure that there was equitable, meaningful, and representative collaboration with the priority populations. For example, because American Indians represent 26% of the outbreak cases and have higher rates of homelessness, HCH collaborated with the Indigenous People's Taskforce - an organization founded in 1987 to develop and implement culturally appropriate HIV education and direct services to the Native community in Minnesota - to help guide the response to this population and reach people on the streets.  An additional and vital partner was South Side Harm Reduction. Based in South Minneapolis, Southside Harm Reduction Services works within a harm reduction framework to promote the human rights to health, safety, autonomy, and agency among people who use substances.

Further coordination occurred with providers at the Positive Care Clinic and Addiction Medicine Clinic at Hennepin Healthcare. Hennepin Healthcare is an integrated system of care that includes a nationally recognized Level I Adult and Pediatric Trauma Center, an acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. When a patient tests positive for HIV, they are referred to the Positive Care Center, an HIV care center of excellence, for case management and further treatment.

An additional and vital partner is the Red Door Clinic, Minnesota's largest STI and HIV clinic, that provides testing and phlebotomy support for HCH. Each collaborative partner has made the implementation of the pilot project possible.

Estimated costs for the project included personnel costs for the medical outreach team of 1.0 FTE RN and 0.3 FTE NP, for a total annual cost of $178,568. Most of the cost of PrEP medication and laboratory tests, based on PrEP clinical practice guidelines, was covered by Medicaid or other patient insurance. Health Care for the Homeless can cover the costs for people who are uninsured until they are able to enroll in a public healthcare program.

An outcomes evaluation of the pilot project demonstrates its success. Data were collected by HCH outreach providers and entered in patients' electronic health records as service was provided. Performance measures included: the proportion of people interested in PrEP who completed an intake, had a negative HIV test, and had blood drawn for lab tests who began taking PrEP medication; the proportion of people who initiated PrEP and continued taking their medication for more than one month; and the proportion of people who initiated PrEP and were still taking their medication after six months.  More than 100 patients indicated an interest in PrEP, 38 completed phlebotomy to initiate PrEP, 23 patients were prescribed PrEP, 15 patients continued PrEP for more than one month, and six patients have continued PrEP for at least six months. Furthermore, the pace of HIV diagnoses being added to the outbreak has slowed the last several months. Although preliminary, this may be a sign that the pilot project is having an impact on the health outcomes of the target population. An additional short-term outcome of this project is that more than 100 individuals have been educated about PrEP, which will hopefully translate to more prescriptions being offered to a highly vulnerable population in the future.

Despite the success of the pilot program, there were some challenges encountered by the HCH staff as discovered in the process evaluation of the program:

Follow-up:

Patients are interested in PrEP, but consistent follow-up is challenging even within a low barrier model. The biggest challenge is locating people for follow-up, and inclement weather plays a role.

Staff:

More provider hours are needed. There were no dedicated additional provider hours until June 2021 for this pilot, and there are currently only 12 provider hours a week for this patient population which includes HIV care, Hep C cure, STI screening and treatment, hospitalization follow-up and coordination for acute infection, other care/coordination needs as they present and the PrEP pilot project. More RN hours are needed. Currently there is one full-time RN to manage the patient panel of the provider, build/respond to community partnerships, follow-up on referrals, conduct testing/screening, and provide care coordination.

Co-occurring substance use disorders:

Substance use disorders play a great role in and often hinder readiness to take daily PrEP.

Lack of housing and competing priorities:

There are many competing priorities for immediate, basic needs in the unsheltered population (e.g., housing, food, transportation, evictions).

Un/underinsurance and complex health insurance system:

Insurance status is a barrier. Connecting people to MN state health insurance, or programs for undocumented individuals, requires complex navigation.

Overall, however, the process for connecting patients to PrEP access has held up well during the pilot project.

In addition to the process evaluation findings above, other notable lessons learned include:

·       Most individuals who engaged in PrEP have established relationships with HCH (wound care, MAT, care coordination, HIV outbreak response, STI treatment/screening).

·       Few individuals have maintained engagement with HCH for PrEP as their sole focus of care.

·       Many patients would benefit from a combination MAT/PrEP community-based mobile program.

·       Many individuals are interested in Hepatitis C cure and are utilizing PrEP as a means to establish care and readiness for Hepatitis C cure.

·       Many individuals are interested in screening for STI, wound care, and other housing/care coordination needs through the medical outreach team.

·       Most consistent PrEP coordination and follow-up is in the same or similar geographic area to the HIV outbreak, and so medication coordination is happening across HIV status and in conjunction with Hepatitis C cure and other medical care to reduce stigma and promote engagement.

The objectives of the pilot program were met, but as noted in section 3, the sustainability of the project will largely depend on the bandwidth and resources of staff. However, significantly more engagement and follow up occurred between June and September 2021 after adding dedicated provider hours. These patients are in more consistent care.

Next steps include continuing the pilot as outlined and following up again at 12 months. In addition, further action is being planned that will add a case management assistant to facilitate housing assessments, provide case management, and connect to medical and chemical health services. Health Care for the Homeless plans to continue to refine its partnership with the Red Door Clinic to provide onsite phlebotomy for orders placed by HCH and explore utilization of the Red Door Clinic team to assist with patient assistance program paperwork for those that do not qualify for insurance. Furthermore, additional activities are planned to make the pilot project sustainable, including:

         Increasing provider hours and expanding the care team to include others to coordinate medication administration and phlebotomy.

         Consideration of models where PrEP would be available at time of visit (samples/stock medications)

         Partnering with the newly forming HCH buprenorphine team to offer medication-assisted treatment (MAT) options and care coordination.

         Moving towards a culture of offering PrEP to all patients who use intravenous drugs throughout HCH.

         Continuing to improve universal HIV screening for HCH patients through the existing opt-out testing.

         Continuing to offer and expand harm reduction interventions including syringe services and coordination with community partners for harm reduction.

Stakeholders are invested in the success of this project, especially due to the ongoing HIV outbreak in our region. Stopping the forward transmission of HIV in the unsheltered homeless population, particularly among people who inject drugs, is key to getting the outbreak under control. PrEP offers a way forward and this innovative pilot project expands access to populations that have not typically had easy access to highly effective biomedical HIV prevention.