At Open Health Care Clinic (OHCC) in Baton Rouge, Louisiana, fighting the spread of COVID-19 meant stopping service to people facing risks of a global epidemic: HIV. In March, the HIV service organization and community prevention clinic suspended rapid HIV testing following an order from the state. "Before this, we were testing Monday through Friday, 8 to 4 every day. It was free testing, so [patients] just come, and they get a point-of-care test and get a result in 20 minutes or so," said Dr. Yihong Zheng, Chief Medical Officer of OHCC.
Though clinics are still allowed to perform traditional lab tests for HIV, the Louisiana Office of Public Health (OPH) suspended HIV testing contracts with community based organizations (CBOs) lacking dedicated clinics, and those that could not submit an appropriate COVID-19 mitigation plan or secure personal protective equipment (PPE). For six weeks, from the end of March to the end of April, only two clinics offered rapid HIV testing in Baton Rouge, as CBOs scrambled to create mitigation plans. As of this report, only two of eight CBOs have reopened for testing, and there is no timeline for lifting the OPH suspension. These factors contributed to a sizable drop in HIV testing in an already volatile, high risk region.
The social distanced waiting room at BRASS, one of the only CBOs allowed to reopen with an approved COVID-19 mitigation plan.
In 2017, Louisiana had the 4th highest HIV diagnosis rate in the United States. The Baton Rouge metro area ranked 5th for HIV diagnosis rate among the large metropolitan areas in the nation. In 2018, Black people accounted for 70 percent of newly diagnosed HIV cases and 72 percent of newly diagnosed AIDS cases.
"[W]e used to see about 20, 30 people a day… [now] the daily census is in the single digits," Zheng said. "This is a major interruption."
According to Sam Burgess, director of Louisiana's STD/HIV/Hepatitis Program, the average monthly number of HIV tests by CBOs and healthcare clinics statewide in 2019 was 2,334. In March, there were only 1,501 tests reported—most of those were done in the first half of the month. There were 1209 tests in the first half of the month and only 292 tests in the second half. OPH officials say this downward trend is likely to continue.
Shaking the Trees
Though healthcare facilities still conduct the vast majority of the nearly 115,000 HIV tests completed every year in Baton Rouge, tests conducted by CBOs serve a critical purpose in expanding access across communities.
"The [CBOs] were really out there kind of shaking trees, trying to convince people to get tested," Burgess said.
There are two kinds of HIV tests: laboratory-run tests (blood draw) and rapid HIV antibody tests (finger-prick or oral swab). Lab-based tests are protected by the Health Insurance Portability and Accountability Act (HIPAA), and can only be conducted confidentially, typically with insurance, and with all results reported to the OPH. Rapid tests can be performed anonymously; the person tested does not require insurance, referrals, and only needs to provide basic demographic information.
"[W]e used to see about 20, 30 people a day… [now] the daily census is in the single digits," Zheng said. "This is a major interruption."
CBOs mostly carry out rapid tests on demand, at free testing events, and through mobile testing units that travel through communities, with regular visits to stops residential substance abuse treatment facilities. The loss of these free and anonymous services, combined with new entry barriers at clinics, such as temperature checks at the door, cause concern that even fewer people will get tested, especially those who are mostly shut out of the healthcare system. "[W]e're talking about folks who don't frequent a doctor's office or an emergency room… So the [CBOs] that we are directly supporting are ones that are reaching our priority populations, which are Black and Brown individuals, gay, lesbian, bisexual, transgender," Burgess said.
COVID-19 testing protocol in BRASS waiting room. On May 27, BRASS started a limited mobile testing service to get back into the communities it serves. Before COVID-19, 85% of their tests were conducted outside of its physical location.
One of the two CBOs in Baton Rouge that submitted an approved mitigation plan to continue rapid HIV testing was Baton Rouge AIDS Society (BRASS).
"Normally we have a counseling session for intake and results where we could talk to you for 20 minutes. We don't do that anymore. Everything is with technology," said the Rev. AJ Johnson, BRASS Founder and CEO. The mitigation plan focuses on creating a new text message protocol for appointments, PPE requirements and staffing changes to limit contact, and screening clients and staff for COVID symptoms. "We used to create a very personal atmosphere, and during this time you really can't get that kind of service…. [now] there's a cut out in the plexiglass for you to just put your hand through."
Despite reopening, client numbers are still down significantly.
"Before we used to test anywhere from 15 to 30 people a week. And when all this hit, it was like six people a week… We had a client actually say that, 'Man, nobody cares about no HIV, they need a corona test.' He was in [a] car and he rolled down his window and shouted it out at us."
Linkage to Care
Fortunately, access to healthcare post-HIV diagnosis has not been significantly hindered by COVID-19 restrictions. "Maintaining HIV care is a critical and essential health function. And we definitely did not want to see that scaled back… [Clinics] have had a harder time getting people to come in," Burgess said. "I think people just aren't clear what's considered a high priority versus something that they could defer. With newly diagnosed people, hopefully the message is clear: This is a high priority. Don't wait."
"We had a client actually say that, 'Man, nobody cares about no HIV, they need a corona test.'"
Zheng confirmed that treatment systems are still functional at OHCC, citing a recent patient encounter where a patient tested positive and was immediately connected to appropriate care services. Johnson also confirmed that positive HIV screens from BRASS were referred out to other sites for treatment.
Sustainability of CBOs
Weekly calls between the OPH and their funded CBOs assess losses, current strategy, and the future post-crisis. "For those community based organizations, reimbursement is directly tied to them actually testing, so they are definitely hurting right now," Burgess said.
Before COVID-19, CBOs received the fee-for-service up to a certain total test cap per month. The OPH has discussed removing the cap on total funded tests-per-month after CBOs are allowed to reopen. The goal is to make up for the lower testing total through Louisiana's Stay-at-Home order and phased re-opening, which was announced on May 11. This would help Louisiana's HIV-test-per-year figure for 2020 recover and financially benefit smaller CBOs that rely heavily on this revenue stream. "We are going to double down on our efforts and try to rebound from whatever the declines may have been," Burgess said.
Zheng described the rapid testers and OHCC staff's employment as, "very secure." She said, "many [prevention employees] have reassigned job duties like these door screeners. We never had this kind of job before. And now the STD RNs are doing triage… talking probably to the same kind of people, but relocated to a different building and then guiding [patients] on the phone more." There has been no pay reduction for employees of OHCC thus far, and the agency is receiving funds from the federal Paycheck Protection Program.
Testing Today
So, who's still testing?
Clinics—like OHCC, Our Lady of the Lake Mid-City Early Intervention Clinic, and CareSouth Medical and Dental—are all currently open for both rapid and lab-based HIV testing, along with primary care providers and hospitals. BRASS is also open for rapid testing. State Correctional Facilities have reported to the OPH that they have continued their regular screenings with COVID mitigation efforts in place.
For most hospitals, regular screenings are opt-in in the emergency room—with the exception of Our Lady of the Lake Hospital, Oschner, and Women's Hospital emergency rooms where HIV testing is opt-out. Opt-in testing means the patient needs to ask for the test to be performed. Opt-out testing means the patient needs to decline or the test will be performed under routine care.
For the Department of Corrections, regular screening is opt-in at intake and re-entry. However, special opt-in population-level testing efforts across the Dept. of Corrections for HIV, Hepatitis B and C, and Syphilis have stopped due to exposure risk to COVID-19 for providers and incarcerated people. However, according to Burgess, treating people already identified with HIV and Hepatitis C has remained a "high priority" at correctional facilities.
"When we roll down the window, we have the plexiglass up. It's only your hand that we're going to get."
The Louisiana Health Hub now offers "COVID Updates," which outline how STD/HIV-related care is being handled statewide, organized by region. However, the list of test sites and services is not exhaustive. While specifics vary, nearly all CBOs and clinics statewide have been and continue to operate on reduced hours allowing for increased sanitation and mitigation efforts.
Johnson says testing strategies at CBOs are changing.
"In our physical location, 15 percent of the people we test a year come here. The other 85 percent are in the community. If you're going to get people tested to know their status, we got to go to them. But with the [COVID] virus, people are not coming out as much as they used to."
To combat this, BRASS launched a drive-by-testing program on May 27. Clients can request an HIV test at an agreed location within a certain distance from the facility. A pair of testers in an SUV drive out with PPE and rapid HIV tests to the location. The testing interaction is limited to the two testers and the person being tested.
"So we would have done all the communication and counseling via text or phone call. When it's time to get tested, we're gonna have the same type of plexiglass [as in the clinic] set up in the car. When we roll down the window, we have the plexiglass up. It's only your hand that we're going to get. A negative test result is under two minutes. If a person has a positive test result, we're going to have them come in the vehicle and of course then we'll be required to wear a mask. Then we do referrals."