Street Medicine Interventions for People with HIV who are Unsheltered - Capacity Builder Provider (HRSA-25-055) and Street Medicine Interventions for People with HIV who are Unsheltered - Evaluation Provider (HRSA-25-057)

The Capacity Building Provider (HRSA-25-055), the Demonstration Sites (HRSA-25-056), and the Evaluation Provider (HRSA-25-057) will collaborate to achieve the initiative's goal and five objectives: Goal: Adapt, document, implement, evaluate, and disseminate street medicine interventions that effectively respond to the needs of people with HIV who are unsheltered. •Objective 1: Build capacity of demonstration sites to effectively respond to the health care needs of people with HIV who are unsheltered. •Objective 2: Achieve successful uptake and sustainability of adapted and implemented interventions by RWHAP recipient staff and clients. •Objective 3: Conduct a rigorous multisite evaluation grounded in implementation science across demonstration sites. The evaluation will assess barriers and facilitators to implementation, implementation strategies, and cost, among other implementation, and client and services outcomes. Evaluation findings will be documented and shared throughout the initiative to support successful implementation. •Objective 4: Develop and disseminate user-friendly, multimedia implementation materials that will serve as a tool for other RWHAP settings to replicate street medicine interventions and provide enhanced care and support for their clients. •Objective 5: Use the Centers for Medicare and Medicaid (CMS) Place of Service Codes that reflect place where services are rendered. Street Medicine Overview As a client-centered service, street medicine is designed to bring the services offered in a clinic into the unsheltered spaces where people live, spend time, and congregate such as the streets and wooded areas. As described by subject matter experts globally, street medicine is conducted where people live and must include a change in traditional health care delivery structure to engage those unstably housed. Street medicine is not a new form of health care delivery. Rather, street medicine programs have existed for decades. These programs have demonstrated the ability to provide health care service in an effective manner, resulting in improved health outcomes. Street medicine programs may take a different approach to address components of delivering health care services than traditional health care settings. Some components are the safety, local and state regulations, and selection of services to offer people. Clinic-based and street medicine interventions have different approaches for assuring safety of the teams and clients because of the different environments and availability of resources in each setting. Local and state regulations may determine which health care services can be delivered in which setting and when. These components are important to understand and include in all street medicine programs. Health care delivered in traditional settings, such as a clinic or mobile unit, may not address the needs of those who experience rough sleeping or are unsheltered. Barriers such as facility hours of operation and policies related to entry (e.g., no pets, no carts, requirements for shirts and shoes) impact access to and retention in care. Stigma and discrimination may be other factors that prevent those with previous poor experiences in clinic-based settings who are unsheltered from entering traditional settings for health care. Because people who are rough sleepers or are unsheltered experience a combination of varied social determinants of health challenges, street medicine teams encounter populations with chronic disease co-morbidities, mental health and substance use disorders, and other structural factors requiring innovative approaches (see also Substance Abuse and Mental Health Services Administration (SAMHSA)'s 2023-2026 Strategic Plan). Based on the 2022 RWHAP Services Report, 5.2% of clients served were unstably housed with another 6.9% temporarily housed. Clients who were unstably housed had a viral suppression of 72.4% and people who were temporarily housed had a viral suppression of 84.1%, which is lower viral suppression than those who have stable housing. To end the HIV epidemic in the United States, strategies that tailor services to meet the needs of people who are not engaged in care or virally suppressed where they are located are required. Street medicine, as a form of health care delivery, can be an effective intervention to help RWHAP clients who are not well served by traditional health care delivery systems. Therefore, while street medicine focuses on those people who are unstably housed, it can also serve those who are averse to a traditional clinic building environment.