Working in a broken system

The difficulties associated with HIV treatment and care are evolving in San Francisco. With ready access to quality HIV care providers, and potent and effective HIV medications, connecting clients with quality HIV care is sometimes the most straightforward part of a case manager’s job. Much more daunting are ways in which other concerns—especially housing instability—affect clients and impact their ability to care for HIV.

“Being marginally housed or chronically homeless is a big barrier to HIV care,” said Jamal Bey, medical case manager for Black Health Center of Excellence. “You don’t have anywhere to take your medications, or store them. It can even be more difficult to get to your medical appointments if you’re not housed.”

“My clients who are experiencing homelessness—I’m concerned with how they are taking their medications. Where are they storing their medications? And how is that affecting their viral load? It’s hard to separate the two—medical care and housing,” said Marguerite Barrett, case manager for the Chronic Care HIV/AIDS Multidisciplinary Program (CCHAMP) Center of Excellence at San Francisco AIDS Foundation.  

Center of Excellence (CoE) case managers reach extraordinarily vulnerable members of our community—people who may be undocumented, who have experienced violence and trauma, who sleep in shelters or on sidewalks, who struggle with psychosis or take drugs to stave off loneliness and cope with trauma.

CoE staff work with clients to connect them to HIV care, help them get to medical appointments and suppress their viral loads. On top of that, case managers help clients address other issues that can stand in the way of successful HIV treatment—including lack of housing.

“We know that the housing market is even challenging for average folks in San Francisco. For people who are on a fixed income, or trying to get on Social Security, it’s even more difficult,” said Irene Snyder, case manager for CCHAMP.  “Clients come to us with goals and expectations. But we’re working in a broken system. San Francisco has so much money, and so many resources. But not enough affordable housing.”

Typically, more than half of CoE clients at any given time are homeless, unstably housed or in unsafe housing. Staff estimate that about 25% are part of in-patient substance use treatment programs (and who may not have housing after the 90-day program ends), and only about 25% have a safe and stable place to call home.

“We’re medical case managers, not housing case managers,” said Barrett. “But housing really is health care.”

Employing a creative system of “workarounds,” the teams use every resource at their disposal to try to secure housing for their clients, with the knowledge that they are fighting an uphill battle. Nearly 7,500 people are currently homeless or unstably housed in San Francisco, shelters are filled to capacity, and safe and affordable housing options are difficult if not impossible to find. They’re used to waiting, and disappointment.  

“The successes are few and far between,” said Bey. “We’d like them to be more frequent, but it can take a long time. We might be working with a client for two years before they get housed.”

“If I have a client facing eviction, or who is getting discharged from a substance use treatment program, the only option that day might be for me to give them a tent. That’s the reality a lot of the time,” said Barrett.

“It can be really difficult, but we celebrate every success—even the tiniest ones,” said Morty Diamond, LCSW, manager of CCHAMP and Black Health CoE. “We know that there are a lot of challenges, and that things can be cyclical. Some clients come back for years. But we’re here for them. We’re here and we play the long game.”

Bey said that he’s seen many clients over the years who have made positive changes in their lives, both big and small. Many seek case management services with viral loads in the hundreds of thousands, or millions, and have seen their viral loads drop to undetectable levels with consistent treatment once they are housed.

Even if clients aren’t able to secure housing, the teams of case managers work with clients to stabilize their lives in other meaningful ways. Often times, case managers become trusted partners that clients rely on as they work to end abusive relationships, as they seek medical care, re-connect with families and more. 

“It’s fulfilling to see people inspired and transformed,” said Bey. “Everybody deserves a chance at hope. That’s something we provide.”


Are you passionate about advocating for affordable housing in San Francisco, and want to get involved? Learn more about Proposition C, “Our City, Our Home,” the San Francisco ballot measure passed in November that will fund affordable and supportive housing in San Francisco. Join the Prop C “Lessons Learned & Next Steps” event at GLIDE (330 Ellis in San Francisco) on December 5, 2018 from 5:30 – 7:30.

Join the HIV Advocacy Network at San Francisco AIDS Foundation to advocate for policies affecting the HIV community by texting SFAF to 52886.

Black Health Center of Excellence and CCHAMP at San Francisco AIDS Foundation are provided in partnership with the UCSF 360 Wellness Center and the Positive Health Program at Zuckerberg San Francisco General Hospital.  

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