Economic Justice for HIV Care

Principal Investigator: Paul Wesson 

Budget: $576,840 

Start Date: March 1, 2025 End Date: February 28, 2027 

Project Abstract: One-in-seven people living with HIV (PWH) experience incarceration annually. HIV prevalence among those with criminal legal involvement (CLI) is 3x higher than the general population. Upon release, PWH-CLI encounter competing priorities and structural barriers to addressing unmet basic needs, resulting in suboptimal care cascade outcomes. Guaranteed income (GI) through unconditional cash transfers can improve mental health, meet basic needs, and boost employment prospects. However, its effects on PWH-CLI, who face unique post-release challenges affecting HIV treatment retention and viral suppression, remain uncharacterized. 

Our three-arm pilot study will assess the feasibility, acceptability, implementation requirements, and preliminary efficacy of a GI intervention to improve HIV care in PWH-CLI released from the San Francisco County (SFC) jail. We will randomize 39 very low-income patients (income <30% of area median income) discharged to a SFDPH network HIV clinic, to 1 of 3 arms: A) one lump-sum payment of $6,750; B) 9-monthly installments of $750; or C) “preference” (patient chooses either A or B). We will offer up to 4 opt-in financial mentoring (FM) sessions during the pilot to bolster GI impacts. Clinical appointment and viral load outcome data will be collected from medical records. All patients will complete quantitative surveys (1 baseline, 2 follow-up) to assess GI experience, patient context, and acceptability. Baseline and endline qualitative interviews with patients (n=12; 4/arm) will explore the GI experience, impacts on HIV treatment, and critical implementation questions to inform future research and policy. Qualitative interviews with system partners (n=10) will explore community perceptions of GI and opportunities to integrate GI in HIV programming and policy.  

Given PWH-CLI’s economic and social marginalization, we will leverage our existing retrospective cohort of PWH-CLI released from SFC jail (n~700 patients; 2018-2022) as historical controls to test preliminary efficacy against pilot participants – comparing clinical appointments and viral load – instead of utilizing a concurrent no-GI control group. Variation in GI disbursement will provide needed data on acceptability and preliminary efficacy of distribution modes and the role of patient agency in pilot outcomes and overall engagement – filling a critical gap in the GI literature. 

Principal Investigator: Wei-Ti Chen 

Budget: $675,000 

Start Date: March 1, 2025 End Date: February 28, 2027 

Project Abstract: California is facing a homelessness crisis. In LA County alone, the homeless population increased by 9% between 2022 and 2023. A major contributor to homelessness is income insecurity: fluctuating and inadequate income heightens vulnerability to homelessness, particularly in urban areas like LA County where inflation has sharply increased housing and living costs. Often, individuals with unstable and insufficient incomes must make difficult decisions and choose between housing and other essentials like food and transportation. 

Homelessness significantly elevates the risk of HIV infection to at least 3 times that of the general population. This increased risk disproportionately affects marginalized groups, including sexual and gender minorities and people of color, who are more likely to face income inequality and homelessness. Additionally, homelessness severely impedes the ability of people living with HIV (PLH) to engage in HIV treatment, with many homeless PLH dropping out of the care continuum, resulting in increased likelihood of unsuccessful viral suppression and higher mortality rates. Economic insecurity and homelessness force PLH into survival mode, where daily needs like housing, food, and transportation take precedence, leaving out resources for managing health. 

Integrating housing services with universal basic income (UBI) is emerging as a promising approach for mitigating the adverse effects of homelessness and income insecurity on care engagement among PLH. However, most current research examines the impacts of housing services or UBI separately, leaving a notable gap in our understanding of their combined effects. To address this gap, the aim of this study is to pilot test an economic intervention for its acceptability, appropriateness, feasibility, and preliminary efficacy in promoting healthcare engagement among 24 PLH experiencing housing instability in the LA metropolitan area. This intervention will consist of UBI, housing services, and the combination of UBI and housing service, allowing for a more accurate evaluation of their implementation outcomes and impacts on health care engagement, both as individual components and in combination. Comparative studies to better understand the potential synergies of these interventions in promoting care engagement among Californian PLH with housing instability are urgently needed. 

Principal Investigator: Erik Storholm 

Budget: $591,351 

Start Date: March 1, 2025 End Date: February 28, 2027 

Project Abstract: Economic marginalization significantly impacts racially and ethnically diverse transgender and nonbinary (TGNB) individuals in the Ending the HIV Epidemic (EHE) priority region of Los Angeles County (LAC), leading to high levels of housing insecurity, homelessness, and poverty. Poverty is a fundamental driver of elevated HIV prevalence, poor HIV care engagement, lower viral suppression, and syndemic conditions such as violence and mental health burdens. TGNB individuals are more likely to engage in criminalized sex work, increasing risk for both violence and adverse HIV outcomes. Preliminary findings from our work with TGNB persons in LAC reveal significant economic and structural barriers to HIV care engagement and viral suppression such as transportation difficulties, employment and housing insecurity, undocumented immigration status, and stigma in employment and healthcare settings. Overall, there is an urgent need for innovative economic justice interventions that support care for HIV and related syndemic conditions among diverse TGNB populations in LAC. Leveraging a 7-year partnership between the Los Angeles LGBT Center’s Trans Wellness Center (TWC) and local researchers, we propose to develop and rigorously pilot-test Trans Wealth, a guaranteed income (GI) intervention for TGNB persons affected by HIV and poverty. We will enroll 30 TGNB individuals who are living with HIV, experiencing poverty and/or homelessness, and virally unsuppressed. Volunteers will either receive 6 monthly payments of $1,000 or a one lump sum payment of $6000, combined with supportive programming from the TWC’s Transgender Economic Empowerment Program to set goals, gain financial literacy, engage in educational and/or employment planning, and legal services. GI interventions have shown evidence of producing positive health and financial outcomes. We will use community-engaged implementation science frameworks to guide the development and delivery of Trans Wealth. Quantitative measures will include biospecimen collection (viral load, CD4 cell count), and assessments of mental health, quality of life, and violence exposure at baseline, 2, 4 and 6-month follow up visits. We will gather qualitative feedback from participants, staff, and community advisory board members to gather data on the acceptability, appropriateness, safety, and feasibility of the Trans Wealth intervention.