Abstract
Introduction
Social determinants of health (SDOH), including housing instability, food insecurity, and transportation barriers, disrupt healthcare engagement and human immunodeficiency virus (HIV) treatment outcomes among people receiving Ryan White HIV/AIDS Program services. Standardized SDOH screening tools exist, but evidence on whether they can be feasibly integrated into routine HIV clinic workflows, alongside existing case-management resources, remains limited. This study evaluates the feasibility and acceptability of implementing a standardized SDOH screening and case-management linkage workflow in a Ryan White HIV clinic, and explores whether case-management engagement is associated with viral suppression in both a prospective screening cohort and a retrospective clinic population.
Methods
This study uses separate prospective and retrospective components, analyzed independently. Case-management engagement for both components is assessed through CAREWare, the case-management data system used by the program; HIV viral-load outcomes for both are obtained from the electronic health record (EHR).
In the prospective component (October–December 2026), eligible patients complete an SDOH screening survey addressing domains including housing, food, transportation, employment, and social connection. Participants who identify needs may request information, referral, or connection with case-management services, including a same-day warm handoff when feasible. Patient perceptions of the screening process are also collected. Primary prospective outcomes are screening feasibility, acceptability, and case-management linkage. Viral suppression (200 copies/mL) is evaluated as an exploratory outcome using the qualifying baseline and subsequent follow-up viral-load measures defined in the study protocol.
The retrospective component includes the Infectious Disease (ID)/Ryan White patient population from January 1 through August 31, 2026. Case-management utilization is determined from CAREWare encounter data, and the most recent qualifying viral-load result during the period is categorized as suppressed (200 copies/mL) or not suppressed (≥200 copies/mL).
Results
For the prospective cohort, results will describe screening feasibility and acceptability, the frequency and type of identified social needs, and case-management linkage. For both cohorts, results will describe exploratory patterns between case-management engagement and viral suppression. Missing follow-up laboratory results will not be interpreted as treatment failure.
Conclusion
This study will assess whether a brief standardized SDOH screening process can be incorporated into routine Ryan White HIV clinic care and connected to existing case-management resources without creating an impractical workflow burden. Findings may inform whether the approach is feasible for continued clinical implementation and provide preliminary information regarding its relationship with HIV viral suppression.