This year’s 2022 World AIDS Day slogan, Equalize is a call to action and as the Joint United Nations Program on HIV/AIDS (UNAIDS) describes, “a prompt for all of us to work for the proven practical actions needed to address inequalities and help end AIDS.” It inspired us to explore how HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) researchers in the University of California system are working to address inequities for historically marginalized communities and lessons learned from the COVID-19 pandemic’s impact on people living with HIV/AIDS.

The Interruption of Essential Service Delivery

The most immediate shift was from the interruption of healthcare service delivery–a challenge experienced across populations, particularly marginalized populations.

Miranda Hill, PhD, MPH, UC postdoctoral scholar-fellow with the Center for AIDS Prevention Studies (CAPS) at UCSF found challenges to care access with gay and Black bisexual men she worked with in Atlanta. “The limited clinical hours and Covid-19 protocols made it more difficult and tedious to get in for prevention and treatment services compared to when you could just walk into the clinical setting and get what you needed,” she says.

Jae Sevelius, PhD, recently a professor at UCSF medical school now at Columbia University, is a clinical psychologist working with transgender communities of color impacted by HIV in a peer support setting. “I’ve always been a huge proponent of providing face-to-face in person service delivery for trans women,” says Dr. Sevelius. “We had to do an extreme pivot to deliver these interventions online with people who don’t have great access to technology.”

Likewise, Ricky Bluthenthal, PhD, professor of population and public health sciences at the University of Southern California, and a featured speaker at the 2022 UC Global Health Day at his alma mater UC Santa Cruz, sees similar ruptures in service delivery to the people who inject drugs due to the COVID-19 pandemic. “Reports indicate that there was a decrease in access to HIV prevention materials, to clean needles and to the opioid overdose reversal drug, naloxone,” he says.

Increased Housing Instability Crisis

One of the other major issues across marginalized groups was the lack of stable housing made even worse due to the pandemic.

“Being unhoused and displaced has a profound impact on people’s abilities to take care of themselves,” says Dr. Bluthenthal. In a recent BMC Public Health study, his team found in his research that unhoused or displaced people who inject drugs are more likely to engage in risk behavior. And because COVID-19 impacted access to stable housing more people who inject drugs found themselves without housing. In fact, a paper his team is finalizing found that only 10 percent of people got housing and only 45 percent got vaccinated.

“Social distancing was really hard for people to do when they don’t have access to stable housing,” says Dr. Hill. She heard particularly from young Black gay and bisexual men that social distancing required them to be home in their subpar housing arrangements that used to be just a place to sleep. Going out and being around their community was once the refuge, but the pandemic stripped that from them.

And Dr. Sevelius saw housing instability, especially among younger trans women during Covid. As a result, they reached out to the older peer leaders who had more stability to crash on their floor, making social distancing difficult. “It improved once they implemented the hotels as temporary housing for folks, especially in San Francisco,” they say. “Some participants had access, but once that ended, their housing instability increased.”

Positive and Eye-Opening Outcomes

Interestingly, there were some positive insights that came out of the intersection of both the Covid-19 and HIV/AIDS pandemics.

Eric Goosby, professor of Medicine at UCSF and a member of the UC Global Health Institute Black Lives Matter task force and Advisory Council member highlights the importance of the primary care delivery systems. “Many HIV patients responded more to Covid-mitigating strategies than the general population,” he says. “In that sense, you see the value of consistent primary care because people living with HIV have regular and ongoing service providers as an anchor they trusted to receive information from.”

Dr. Hill heard from providers in Atlanta that the shift to virtual care and in-home doctor visits actually increased access to resources among people living with HIV within an urban setting. “Where healthcare providers were providing that more options, people had higher care management,” she says.

Dr. Sevelius saw this advantage in cases where healthcare providers supported patients with the technology learning curve giving them access to telehealth. “They had this option to avoid healthcare settings where they wouldn't be stigmatized or go to an office and feel awkward or wonder what name the receptionist would call out,” they say.

Policy Implications

Both the positive and negative outcomes from the past three years provide insight into the policies that can truly serve marginalized people living with HIV.

“Housing first is good,” says Dr. Bluthenthal, “but we have to uncomplicate the process. I also think at the end of the day we need to move towards policies like universal basic income that guarantee people regardless of health status adequate housing, food, and security.”

Dr. Hill has a similar sentiment. “If anything, resources should be going into those communities instead of people who are not a part of those communities,” she says. She emphasizes that people within communities know what they need and they’re creative and resourceful.

Dr. Sevelius sees there being two important implications. One around providing pathways for folks to increase their technological literacy so that they can access more options. The other is to address mental health needs. “For people who are already marginalized or have history with trauma, the pandemic was especially challenging with the social isolation,” they say.

“There’s so much funding for HIV research but so little of it goes to how we support peoples’ mental health.”

How We Equalize

COVID-19 severely impacted people living with or impacted by HIV, particularly those from historically marginalized groups. Similar to other healthcare issues, it exposed the deeply rooted existing inequities. With this year’s World AIDS Day theme, Equalize, we take to heart the recommendations from the people who work directly with the most impacted groups. For that, UCGHI is doing the work to center the most historically marginalized people in order to ensure we are focusing our work where it means the most.