HIV prevention case management in San Francisco: Barriers to successful implementation

Abstract

Prevention case management (PCM) is the most labor-intensive HIV prevention intervention for persons at risk for acquiring or transmitting HIV. However, it has not been thoroughly evaluated. We abstracted client charts (n = 290) from 12 San Francisco PCM programs and interviewed current and former program directors (n=16), case managers (n = 17) and contract managers (n = 4) regarding client characteristics, services delivered, barriers to care, cost and organizational structure, policies and procedures. Most agencies lacked protocols and data collection forms, had high staff turnover, inadequate staff training and supervision, experienced difficulty recruiting and retaining clients and could not implement PCM guidelines. Half the clients lacked behavioral risk assessment, 39% were low or no risk, a third received HIV prevention education and a third received referrals. Including time spent directly with clients and working on their behalf, PCM cost almost four-fold more per client contact than the next most costly individual level prevention intervention. Local PCM guidelines, reimbursement ties to providing and documenting services and increased collaboration between the health department and agencies has greatly improved the situation. Outcome evaluations and cost-effectiveness assessments comparing PCM to less costly prevention interventions are needed.

Acknowledgments

We are indebted to Mike Pendo for directing the project's Community Advisory Board, leading the development of the San Francisco PCM Standards and Guidelines and providing editorial assistance. We are also indebted to our field staff, Eileen Loughran and Carla Clynes. We would like to thank Stella Cheung, Art DeGuzman and Aida Flandez for data management and administrative support. Staff who assisted with the development of interviews and data collection materials included: Kristen Clements, Elizabeth Davis, Anne Hirozawa, Hilda Jones, Jimmie Naritomi, Billy Pick, Peter Twyman and Joe Wright. Members of our community advisory board were very helpful and included: Leonel Angeles, Crystal Catamco, Bernard Henderson, David Indest, Janetta Johnson, Sacul L'Adnbre, Oscar Macias, John Newmeyer, Cindy Pangelina, Carla Dillard Smith and Sonny Vharabukka. We extend thanks to the staff of our collaborating agencies for their willingness and enthusiasm in working with project staff: API Wellness Center, CAL-PEP, Filipino Task Force on AIDS, Glide-Goodlett HIV/AIDS Project, Haight Ashbury Free Clinics, Institute for Community Health Outreach, Instituto Familiar de la Rasa, Mission Neighborhood Health Center, Native American AIDS Project, New Leaf Services for the Community, New Village, Proyecto Contra Sida por Vida, San Francisco AIDS Foundation, San Francisco City Clinic, San Francisco Human Rights Commission and Tenderloin AIDS Resource Center.

This study was funded through the Evaluation-Capacity Building Component IV of the 1998–1999 CDC Supplemental Cooperative Agreement.