COVID-19 National Rapid Assessment Preliminary Report
The institutional impact of COVID-19 on organizations of color providing HIV/STI/HCV services to people of color across the U.S., Puerto Rico, U.S. Virgin Islands, and Affiliated Pacific Island Jurisdictions
Organizations that have been providing long-standing and proven-effective HIV/STI/HCV services to communities of color are now struggling to provide vital services while also addressing our newest pandemic, COVID-19. This challenge has been exacerbated within our communities of color which have suffered the long-term impact of health inequalities and of being at ground zero for both pandemics. When organizations, such as these, are under acute stress, they are more likely and, in many cases, need to operate in survival mode, which means that attention is more narrowly focused on the immediate, the here and now. As such, these organizations may struggle to implement their strategic plans; leadership may have difficulty providing adequate staff support; and organizations may not be prepared to make informed, and sometimes difficult, programmatic and funding decisions.
The Black AIDS Institute, San Francisco Community Health Center, and Latino Commission on AIDS, three organizations which have worked collaboratively over many years and are led by and serve people of color, joined forces to create the Stronger Together Partnership (STP) in April 2020. Working with over 57 other organizations, STP is assessing the institutional challenges posed by the Novel Coronavirus (COVID-19) to the provision of HIV/STI/HCV services to communities of color in the U.S., Puerto Rico, U.S. Virgin Islands, and the Associated Pacific Island Jurisdictions. To proactively support organizations in achieving the 2030 goals for Ending the HIV Epidemic and plans for the elimination of Hepatitis, while simultaneously responding to the impact of COVID-19 on communities of color and the organizations serving them, the first critical efforts of STP include the creation of a COVID-19 National Rapid Assessment and a Virtual Strategic Think Tank.
The COVID-19 National Rapid Assessment is looking at (a) the impact of COVID-19 on the ability of organizations and their workforce to continue providing HIV/STI/HCV services and the strategies enacted to continue providing them; (b) their capacity to address emerging COVID-19-related needs among their clients/consumers; and (c) their capacity to integrate COVID-19 services as an added focus for their short- and long-term institutional strategies.
In order to assess the ways that organizations are meeting the challenges of providing services in the time of COVID-19, we are conducting purposive sampling of 90 organizations across the U.S. and its Territories to encompass a variety of institutional settings, organizational sizes; populations served, and geographic locations. The purposive sampling takes into consideration those organizations that serve primarily people of color, have people of color in upper leadership positions, and provide services directly related to the HIV continuum of care and/or high impact supportive services.
This report presents a preliminary analysis of the data collected as of September 25th, 2020. The final report will be updated upon completion of data collection on November 15th, 2020, and will include a more comprehensive and detailed analysis. To date, a total of 35 interviews of upper leadership have been conducted, including 5 in Spanish. A total of 42 program managers and 76 front-line staff have completed the online surveys.
Impact of COVID-19 on clients / consumers
According to HIV/STI/HCV organizational staff, COVID-19 has greatly impacted clients’ health and psycho-social life in multiple ways. They reported delays in HIV/STI/HCV screening/testing, STI/HCV treatment, HIV care, and specialty care. While the impact on health has been considerable and diverse, survey respondents reported an even greater impact of COVID-19 on their clients’ psycho-social life in the areas of mental health, food insecurity, financial stability, and community connectedness and integration. While information on HIV seroconversion or poor HIV clinical outcomes is still scarce, several leadership staff reported on the potential increase of HIV transmission. Furthermore, interviews have shed light on the synergistic impact of long-term inequalities among communities of color on COVID-19 health outcomes.
Impact of COVID-19 on staff
The workforce of these organizations has also endured, and continues to withstand, the challenges of service and organizational disruption in the context of socio-political upheavals in the U.S., including protests against police brutality, hate and racism, xenophobia, and/or transphobia. Given the great impact of COVID-19 on communities of color, it is not surprising that staff, their families, and social networks have been greatly impacted as they often come from these very same communities.
While most organizations have avoided infection or great casualties among their staff by swiftly implementing COVID-19 prevention measures to ensure the safety, well-being, and performance of their staff, many leadership staff expressed concern about the long-term trauma, burn-out risk, and, in some cases, death among their staff and their community and family members. Furthermore, for some leadership staff, the emotional toll of feeling responsible for their staff’s well-being was often compounded with the personal toll of losing family members to COVID-19.
Not only have staff been personally impacted, COVID-19 has impacted them professionally. Staff reported on the challenges of staying focused while working from home or implementing their program activities with limited technological or physical resources. They also have to contend with the overlap of their personal and professional lives. Whether returning to work or working from home, staff with children have felt overwhelmed with the additional home responsibilities due to the closing of schools and day care services.
Impact of COVID-19 on services and programs
As the community’s needs increased, organizations saw the need to increase their service capacity, even while going through staffing, funding, and infra-structure challenges. Faced with these challenges, some organizations have discontinued or scaled down essential services, including core services for homeless populations, incarcerated individuals, and those lacking access to public transportation. While some organizations started providing virtual and telehealth services, others re-started face-to-face services albeit in a restricted manner. Whichever the choice, deciding on which essential services to re-start and prioritize was a painful professional and ethical challenge for many organizations.
COVID-19 has precluded face-to-face contact with clients, disrupted service delivery, and diminished the numbers of clients served. Organizations have canceled or rescheduled major fundraising and community events, incurred costs associated with remote work and health and safety procedures, made hard decisions to prioritize some clients and services over others, and engaged in agency-wide and programmatic review of priorities.
Medically-oriented services can rarely be postponed. Therefore, many clinics and medical settings remained open and provided essential HIV services such as linkage to care, care and treatment. On the other hand, low-threshold services such as social gatherings, community outreach and support groups, necessary to increase client engagement in services, have been greatly impacted due to social distancing measures. Not surprisingly, services that rely on client engagement are also being greatly impacted, including HIV testing, STI/HCV testing, and linkage to PrEP/PEP. In addition to impacting their direct services, COVID-19 impacted the work that organizations were doing in other service areas such as immigrant legal advocacy, leadership development, and peer training.
Impact of COVID-19 on institutional stability
Most organizations have been able to renegotiate their funding contracts, and most staff reported some or sufficient access to immediate resources needed to continue providing services, including policies and guidelines, PPE, work space, and COVID-19 training. However, a significant number of staff reported very little or no access at all to resources needed to adapt and implement services under these new conditions, including training in trauma-informed-care, technology training, and technical assistance to implement programmatic changes. Additionally, some staff expressed concern about the long-term impact on postponed program activities such as program evaluation and quality assurance.
Leadership staff were asked questions related to institutional stability, including the impact of COVID-19 on their finances and strategic planning. Organizations incurred a variety of expenses connected to the epidemic, including those related to safety measures, enhancement of infra-structure, or provision of new services. Organizations were often able to re-negotiate their contracts with funders to allow for these expenses. However, many small organizations have been greatly impacted financially, including several that were not able to implement additional safety procedures such as acquiring PPE or installing plexiglass due to lack of funding.
Uncertainty about the future was felt across organizations, from the small to the larger ones. Many organizations relied on annual fundraisers that were canceled or conducted virtually. Some organizations had received additional assistance through the COVID-19 emergency funds oftentimes made available from private foundations and utilized it to enhance their infrastructure. Other organizations had taken cost-saving measures by delaying the hiring of new staff. Some organizations had healthy finances that allowed them to manage the additional costs associated with responding to the epidemic, often with unrestricted funds. Nonetheless, even organizations with adequate unrestricted funds expressed concern about the long-term sustainability of implementing ongoing safety procedures and work changes.
Engagement in COVID-19 activities
As the COVID-19 epidemic unfolded, some staff reported that their organizations became involved in COVID-19 related activities, including community education about COVID-19 risks, protective measures, testing and treatment. Nonetheless, less than 50% of staff reported being involved in other key activities related to COVID-19 such as contact tracing, counseling to clients with or impacted by COVID-19, or case management to clients with COVID-19. Overall, staff reported a great need for a variety of resources and support in order to address emerging COVID-19-related needs among their clients, from educational materials and training to institutional policies and guidelines for emergency responses. Close to 50% felt that there was a need for technical assistance to integrate COVID-19 within their current HIV/STI/HCV programs.
Most leadership staff at health organizations reported they had already incorporated COVID-19 work within their scope of services, often in partnership with departments of health. Those in social service organizations were less certain about including COVID-19 as an added focus. They expressed concern about their staff’s expertise to move from sexual health to general health, diverting the mission of the organizations, or overextending their capacity without appropriate funding.
Lessons learned and moving forward
While COVID-19 has created numerous challenges to organizations, many of these organizations have been able to take on the challenges by implementing team approaches to problem solving, embracing technological upgrades, and fostering innovation. Many leadership staff have identified lessons learned from this pandemic and are doing their best to see this as an opportunity to develop new strategies and to expand their service portfolio.
Overall, staff reported a rapid increase in the use of new strategies to continue providing services, particularly the use of virtual media to provide counseling, health education, and telehealth services. As expected, many organizations have also rapidly adopted Differentiated Service Delivery (DSD) as a strategy to account for the limitations imposed by COVID-19 on full delivery of services. In some cases, organizations proactively and creatively enhanced their ability to provide services under the new conditions, including digitizing their medical records, providing home testing, delivering sidewalk services and goods, and starting virtual services. Nonetheless, these new strategies had not been universally adopted, e.g., HIV home testing or telehealth.
In addition to service strategies, staff reported on program strategies utilized to continue providing services, particularly the prioritization of program activities and discussing grant requirements with funders, strategies that are also connected with DSD. Some organizations have developed or enhanced partnerships with other organizations to pool resources to provide services such as HIV testing, telemedicine, and educational materials dissemination.
While many leadership staff saw potential for institutional growth in these changes and adjustments, they also expressed their concern about what is being lost in these service adaptations. For instance, the use of social media has resulted in positive outcomes in broader recruitment of clients and delivery of services. Nonetheless, the effectiveness of social media and electronic technology for services was not seen as generalizable across populations, particularly among those experiencing a technology gap due to their financial hardship, age, or geographic location.
More generally, over 50% of staff reported to be somewhat or very concerned about the impact of COVID-19 on service delivery moving forward. About 50% also reported to be somewhat or very concerned about their programs’ ability to achieve overall program goals, complying with deliverables and funding requirements. Many leadership staff expressed concern about the future outlook of HIV, COVID-19 infections, and poor vaccination rates. In the short-term, leadership staff reported some level of uncertainty about the future landscape of services and funding. In the long-term, some leadership staff, particularly in the Southern States and in Puerto Rico, expressed concerns about the diversion of funding from HIV towards other health issues and the persistent geographic disparities in achieving the goals to End the HIV Epidemic.
- While the use of the electronic and virtual may mitigate the impact of COVID-19 on the provision of client engagement activities, the technology gap (hardware, proper software and quality of internet) among low-income individuals and those living in rural areas must be addressed.
- Supportive services for those at risk of HIV infection or living with HIV must be enhanced to address the exacerbated impact of COVID-19 on those already experiencing mental health issues, isolation, substance use, food insecurity, housing instability, and financial instability.
- Strategies to address burn-out, PTSD, and mental illness among staff need to be implemented and funded, including the presence of clinical support, time off, and childcare.
- Small organizations must receive infra-structure funding to continue providing HIV/STI/HCV services in particular geographic areas and to particular populations to ensure the goals of Ending the HIV Epidemic and elimination efforts on HCV are achieved across the U.S.
- Funding should be made available for critical institutional infrastructure enhancement, including staff development, technology upgrade, financial planning, contingency emergency planning, program innovation strategic and succession planning.
- Research support and funding should be made available to organizations for program adaptation and for the development of original virtual interventions.
- Emergency plans at the local, state, and federal levels must be critically assessed and updated to ensure that social determinants of health impacting communities of color are taken into consideration.
- There is a need for engagement of communities of color in policy planning (specially on vaccine education, promotion, and provision) and on the COVID-19 related policies, funding, and research.
- There is a need for policy and practice research with a strong community participation to examine in-depth the ongoing changes in public health occurring as a result of COVID-19.