Clinical Scorecard: Accessible Community-Based Care: A Strategy for Involving Individuals with Complex Needs in HIV Treatment and Prevention
At a Glance
Category
Detail
Condition
HIV infection and prevention among people experiencing homelessness and substance use disorders
Key Mechanisms
Low-barrier, whole person, community-embedded care integrating HIV testing, prevention, treatment, and primary care
Target Population
People living homeless, especially those with co-occurring substance use disorders and complex barriers to care
Care Setting
Community-based organizations with embedded clinics located in trusted, accessible locations frequented by the target population
Key Highlights
People experiencing homelessness and substance use disorders face increased HIV risk and multiple barriers to accessing traditional medical care.
Low-barrier, status-neutral clinics co-located within community organizations provide integrated HIV prevention, treatment, and primary care services.
Community-embedded clinics like Aurora–SHE have expanded access and engagement by meeting patients where they already seek services.
Guideline-Based Recommendations
Diagnosis
Implement routine HIV testing integrated within low-barrier community settings to identify infections early among high-risk populations.
Management
Provide trauma-informed, walk-in, low-barrier HIV prevention and treatment services co-located with social support and primary care.
Use a whole person approach combining HIV testing, prevention, and treatment regardless of HIV status to reduce stigma and disparities.
Monitoring & Follow-up
Track viral suppression rates among people with HIV experiencing homelessness to identify gaps and improve care engagement.
Risks
Recognize increased vulnerability to HIV and other infectious diseases due to unstable housing, substance use, and structural barriers.
Patient & Prescribing Data
People experiencing homelessness with complex social and health needs, including substance use disorders
Low-barrier, community-embedded clinics facilitate engagement and retention in HIV prevention and treatment by reducing structural and systemic barriers.
Clinical Best Practices
Co-locate HIV services within trusted community organizations serving people experiencing homelessness.
Offer walk-in, trauma-informed care tailored to the needs of marginalized populations.
Integrate social services such as housing support, advocacy, and basic needs assistance alongside medical care.
Expand clinic hours and staffing to increase accessibility and continuity of care.
Adopt status-neutral models to engage both people living with HIV and those at risk in prevention and treatment.
by Maria A Corcorran, Jimmy Ma, Margaret L Green, Raaka G Kumbhakar, Eve Lake, Elizabeth Dhal Helendi, Luke Sumner, Lorie Ann Larson, Julia C Dombrowski, Shireesha Dhanireddy
