Flexibility Is Key to Providing Ongoing Services to an HIV-Positive Population During the COVID-19 Pandemic

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Washington is home to 2 pertinent developments in the arrival of coronavirus disease 2019 (COVID-19) to the United States: the first US case of the virus was reported in the state on January 21 and the first major US city to report deaths as a result was Seattle.

Washington is home to 2 pertinent developments in the arrival of coronavirus disease 2019 (COVID-19) to the United States: the first US case of the virus was reported in the state on January 21 and the first major US city to report deaths was Seattle.

Populations most at risk from complications of COVID-19 include the homeless, sexual minorities, and persons who inject drugs, among others. These groups of individuals are also disproportionately affected by HIV.

With no prior guidance on which to build and expand, what did Seattle and Washington do to attempt to overcome the lack of available information and channel whatever resources they had to ensure those most at risk of HIV and the current HIV-positive population continued to receive any and all necessary help? A team of investigators recently published their results on such an inquiry in AIDS and Behavior.

“To provide effective HIV prevention and care to priority populations, HIV service delivery must be flexible, familiar, and paired with needed social interventions,” the authors noted.


This meant balancing patient safety and health while addressing 5 key areas:

  1. Program operations
  2. Counseling services
  3. Testing services
  4. Pharmacy services
  5. Other essential services (eg, food, housing, safe social spaces)

Although telehealth has been implemented to great success in other areas, its use among vulnerable populations can be considered a catch-22, especially now. With in-person care having the ability to establish a personal connection with HIV-positive patients, converting them to only telehealth could “trigger feelings of abandonment”—especially for those with lack of access to the necessary technology needed to establish a live telehealth connection.

Possible solutions to continue program and counseling services include combining increasing outreach support with in-person visits when telemedicine is not an option, as well as classifying the most stable patients for whom telehealth is a workable option. Online counseling and support groups are another suggestion, as is not overemphasizing negative or sexually risky behaviors.

To be able to provide safe HIV testing services—in some instances, testing for sexually transmitted infections (STIs), too—during the pandemic, several programs in Seattle started phone screening for COVID-19 symptoms early on, while providing home-based, supervised testing for HIV and STIs. In addition, certain clinics shut down their testing capabilities because social distancing was not achievable, and clients with proven steady adherence to their preexposure prophylaxis (PrEP) regimen are allowed to temporarily forgo testing when they need refills.

Pharmacy services have also been more flexible in that HIV medicine supplies expanded from the usual 30 days to 90 days, thereby cutting back on unnecessary, perhaps unsafe, trips for refills. This mirrors the current CDC recommendation for dispensing up to 90 days of medication for at-risk individuals currently taking PrEP.

With many social determinants of health, such as food, housing, and safe social spaces (all previously mentioned), being adversely affected by the COVID-19 pandemic, the need to ensure that vulnerable populations have these basic needs met is more urgent than ever. To this end, temporary solutions in Washington expanded in novel ways, such as increasing tiny house living. Housing requirements have also been relaxed.

Flexibility is key above all.

“During this pandemic, as well as any other future socially disrupting events, it is important to recognize that adaptations in service delivery that are acceptable solutions for some populations may further harm already disadvantaged populations,” the authors concluded. “Understanding the needs of priority populations, and tailoring HIV and other health services to meet their needs, can minimize long-term health impacts and help reduce health disparities.”


Belma-Sofie K, Ortblad KF, Swanson F, Graham SM, Stekler JD. “Keep it going if you can”: HIV service provision for priority populations during the COVID-19 pandemic in Seattle, WA. AIDS Behav. Published online May 8, 2020. doi:10.1007/s10461-020-02902-5