STRIVES: Status-neutral tele-health concierge intervention for people who use drugs via engagement through street medicine

About This Grant

Homelessness and housing instability represent critical public health challenges in the US with more than 650,000 people experiencing homelessness (PEH) nightly. PEH experience differential health effects across various conditions, including chronic disease, substance use, and HIV, compared to their housed counterparts. An astounding 65% of PEH report having used illicit drugs regularly in their lifetime with 37% reporting regular drug use in previous 6 months. Homelessness and illicit substance use, in isolation and in combination, continue to be significant drivers of poor HIV outcomes and are highlighted as key priority targets under the Ending the HIV Epidemic (EHE) Initiative. EHE has identified evidence-based interventions, including rapid HIV testing, antiretroviral therapy (ART), low barrier clinics, and PrEP that need to be implemented, scaled, and sustained within communities most affected by HIV. To maximize the effectiveness of these interventions among PEH who use drugs and to address the HIV, overdose and homelessness syndemic, comprehensive healthcare models need to be developed, tested, and deployed where they are in comfortable environments that simultaneously address a key driver of HIV, namely untreated substance use disorders (SUD). The HIV Medicine Association has called for the scale-up of street medicine (delivering health services directly to unsheltered individuals where they are), counseling and differentiated service delivery to end the HIV epidemic. We developed, refined, and pilot tested Status Neutral Tele-Health ConcieRge (SN-THR), a telehealth-based, multicomponent care model originally designed for people with who inject drugs (PWID) with HIV then adapted it to include PWID without HIV for prevention via PrEP and MOUD. We hypothesize that SN-THR will increase access to HIV care (testing, prevention, treatment), SUD services, and mental health services through telehealth to augment street-based primary care (i.e. street medicine). We propose to test the efficacy, cost-effectiveness, and implementation of an innovative integrated HIV, addiction, and primary care model—SN-THR—in a street-based setting using a hybrid type I effectiveness-implementation approach. The specific aims are 1) Evaluate the efficacy of SN-THR vs. standard of care (patient navigation to off-site clinic) on HIV treatment and prevention adherence; 2) Perform an economic evaluation of SN-THR and estimate the cost-effectiveness of SN-THR; and 3) Assess the drivers of SN-THR implementation and their impact on implementation outcomes. We hypothesize that more participants in the SN-THR intervention condition will be adherent to ART for treatment or prevention than those in the control condition across 12-month follow-up This application is directly responsive to the priorities of NIDA’s RFA-DA-25-072 by testing a novel telehealth-based, status-neutral care model for integrating HIV and SUD services into street-based primary care for PEH who use drugs.