BACKGROUND/SETTING: In San Francisco, HIV viral suppression is 71% among housed individuals, but only 20% among unhoused individuals. We conducted a discrete choice experiment (DCE) at a San Francisco public HIV clinic to evaluate care preferences among people living with HIV (PLH) experiencing homelessness/unstable housing during the COVID-19 pandemic. METHODS: From July-November 2020, we conducted a DCE among PLH experiencing homelessness/unstable housing who accessed care through a) an incentivized, drop-in program ("POP-UP") or b) traditional primary care. We investigated five program features: single provider vs team of providers; visit incentives ($0, $10, $20); location (current site vs current+additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and navigator assistance. We estimated relative preferences using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity. RESULTS: We enrolled 115 PLH experiencing homelessness/unstable housing, 40% of whom lived outdoors. The strongest preferences were for the same provider (ß=0.94, 95%CI 0.48-1.41), visit incentives (ß=0.56 per $5; 95%CI 0.47-0.66), and drop-in visits (ß=0.47, 95%CI 0.12-0.82). Telehealth was not preferred. Latent class analysis revealed two distinct groups: 78 (68%) preferred a flexible care model; while 37 (32%) preferred a single provider. CONCLUSION: We identified heterogeneous care preferences among PLH experiencing homelessness/unstable housing during the COVID pandemic, with two-thirds preferring greater flexibility and one-third preferring provider continuity. Telehealth was not preferred, even with navigator facilitation. Including patient choice in service delivery design can improve care engagement, particularly for marginalized populations, and is an essential tool for ending the HIV epidemic.
Heterogeneous preferences for care engagement among people with HIV experiencing homelessness or unstable housing during the COVID-19 pandemic