Improving Transportation Access for HIV Prevention in the South

Public Transportation (buses, subways, trains, trolleys, and street cars)

Communities located in metropolitan centers may have more public transportation access than those in rural areas. For communities with public transportation as an option, explore ways to connect clients with passes to use the transportation system, such as bus or subway passes.

Fixed- route bus systems are the most common form of public transportation, yet for many rural communities this model may not be available as fixed-route services can be difficult to access in rural areas.

An example of a public transportation model in a rural setting is the Mountain Empire Transit (MEO). MEO provides demand response services to residents of several rural counties (Lee, Scott and Wise counties and the city of Norton) in southwestern Virginia. While there is not a universal way to look up transportation options in different parts of the U.S, the “availability and access” section below provides some consideration questions the community can use to assess what transportation services exist in their community.

Due to stigma, some individuals may not feel comfortable being dropped off at a community-based organization for services and may not have a private space for tele-health visits. Smaller transportation models could instead transport an individual to another location connected to the CBO, such as a pharmacy or local library for a tele-health visit. Some pharmacies have private rooms and can partner with a CBO on the days the room isn’t being used for services. Additionally, local libraries can also serve as a location CBOs or health systems can partner with for tele-health visits. An example of this is the Pottsboro Area Library located in Pottsboro, Texas. The library offers a private tele-health visit space and has been since January 2021.

Volunteer Models

Some programs can provide transportation services to passengers by engaging volunteers to serve as drivers. An example of this program, though larger in size, is the American Cancer Society’s “Road to Recovery” program. This program connects patients with volunteers for rides to their treatment appointments.

The National Volunteer Transportation Center has a wealth of resources for programs looking to adopt this model, including a document to help plan a volunteer driver program and information on already established volunteer networks.

Voucher Models

Voucher models use tickets or coupons that eligible riders can offer to participating transportation providers in exchange for a ride. This model relies on community partnerships and available transportation modes in a given community. Voucher programs may also include a volunteer component, being reimbursed with vouchers.

The Toolkit for Operating a Rural Transportation Voucher Program provides a model for how to bring together community members and resources to develop and operate a transportation system for people in rural areas.

Coordinated Services Models

This model involves the coordination of individual service programs in a community to improve the efficiency of limited transportation resources. Agencies work together to share resources, knowledge, and funding to increase the number of people being served. Community-based organizations can pool resources together to ensure individuals in the community can access HIV prevention services. This model can be integrated into other planning bodies, such as groups working on implementing their communities Ending the HIV Epidemic in the U.S. plan.

Mobility on Demand

Mobility on Demand models integrate and connect various pre-existing modes of transportation within a community. An organization may serve as a central authority in scheduling and coordinating transportation for several programs and for individuals. For instance, in Oklahoma, the Northeast Oklahoma Tribal Transit Consortium was formed with ten tribes in the region. The collaboration provides tribal transit services to 6 counties and is called “Pelivan Transit”. “This integration of a rural public transportation program (Section 5311) and two tribal transit programs (5311 c) was established with the Cherokee Nation from one grant and two other grants with the Nine Tribes of Northeast Oklahoma Consortium consisting of the Eastern Shawnee, Miami, Modoc, Ottawa, Peoria, Quapaw, Seneca-Cayuga, Shawnee, and Wyandotte tribes of Oklahoma.”

Note: This model is built on pre-existing structures and may take more time to establish in communities without public/private partnerships.

Ridesharing Models

Uber and Lyft typically come to mind when discussing ride-sharing models. Children’s National Medical Center provided Uber Health transportation services to clients experiencing transportation barriers and saw an increase in HIV viral load suppression amongst participants (treatment as prevention). While results from this intervention are promising, this model can be costly.

Connector Services

Connector services provide transportation to and from another transit system and is typically seen in inter-cities. CBOs in communities that have these services should include connector services when discussing ways to travel to the organization. The public needs to be well aware of the routes available to them and the destinations to which services can connect riders.

Mobility Management

Mobility management programs are designed to help individuals learn how to use and connect to transit as well as to connect multiple transportation networks.

The National Center for Mobility Management is dedicated to improving the efficiency of transportation systems and programs in the country, as well as building the transportation workforce. The organization holds trainings, provides resources, and conducts technical assistance to support communities on their mobility management needs.   

Access models are not a one size fits all and depend greatly on community services, available funding and infrastructure. Contact your Project Officer to learn more about allowable expenses included in your Cooperative Agreement.

Availability

What are your community’s transportation assets?

When thinking about ways to improve access to transportation, a recommended first step it to assess the community’s assets, specifically transportation assets. Learning about a community’s strengths and resources can help develop solutions and opportunities to increase transportation access.

These are questions to ask yourself when assessing what assets currently exist and/or when establishing a transportation program:

• Does the community I’m serving have a public transportation infrastructure?
• Are rideshares common in my community?
• Does my community have a transportation planning group?
• Do I or my contacts have a relationship with the local Department of Transportation?
• Does the local health department or CBOs operate mobile units in my community?
• What partnerships does my organization have that can help with transportation access?
• Does your organization have memorandum of understandings (MOUs) with organizations that offer transportation?
• What funding is available to assist with transportation needs?

Access

Even if transportation options are available doesn’t mean they will be utilized. The following are access considerations and questions to think about when offering transportation services.

Is the vehicle labeled or wrapped potentially impacting one’s confidentiality?

Agency vehicles that are wrapped or labeled may make individuals uncomfortable to utilize. While wrapped vehicles help bring awareness to your organization and its services, consider having an unwrapped car for transporting clients and house visits. A client may not want to get into a car with advertising on it as others could see them and assume what services they’re receiving.

If the vehicle is wrapped, consider meeting the client in a mutually agreed upon location, such as a public place or community park.

Are drivers familiar with the communities the CBO serves? Are cultural humility workshops offered?

For organizations working with volunteer drivers, offer cultural humility trainings as a part of their onboarding process.

What times are the services available?

How often in advance does the transportation service need to be requested?

This is important to note when discussing transportation services as ride availability could be limited, requiring advanced notice. Transparency on the amount of time required to get a ride can help individuals plan accordingly.

Are other transportation options available beyond ridesharing?

Due to safety reasons, some populations may not feel comfortable accessing ride shares.

Has the organization implemented COVID-19 protocols to keep drivers and passengers safe during the global pandemic?

Telehealth/ Telemedicine

COVID-19 has pushed more organizations to offer telehealth services. NASTAD has seen an increase in telePrEP programs becoming available over the course of the pandemic, state-specific telePrEP services can be shown on this map.

For programs interested in designing and implementing a telePrEP program, the telePrEP hub toolkit provides helpful resources to assist clinics getting stated.

Organization spotlight: Medical Advocacy and Outreach (MAO) provides services to Central and Southern Alabama, a predominantly rural area. MAO launched telehealth services in 2012 to help meet the needs of their rural community. MAO now uses telemedicine/telehealth to support their PrEP program as well as many other support services. Learn more about MAO’s telehealth services here.

Important Telehealth Considerations

When looking to establish a telehealth program, health equity and access challenges must be part of the conversation, so programs ensure priority populations are able to access these services. These include, but are not limited to broadband barriers, provider and technology distrust, and privacy.

Broadband Barriers

In a study conducted by the Joint Center for Political and Economic Studies on broadband access in the South, Black communities in the Black Rural South lacked affordable, high-quality broadband more than any other group. Broadband access is a major barrier for providing equitable telehealth access. Some telehealth platforms can perform on low-broadband, Washington University and Prime Health developed the Telehealth Video Conferencing Matrix. This resource describes the different platforms and capabilities.

Some possible ways to address these challenges are:

• Providing clients with a device that could connect to the internet, such as a tablet or smart phone.
• Providing internet/ data cards for a tele-visit.
• Developing public health partnerships with telecom companies to work on expanding services to impacted areas.

Technology/ Digital literacy

Technology literacy describes an individual’s ability to assess, acquire, and communicate information in a fully digital environment. Just like health literacy, digital literacy is another important consideration when designing equitable telehealth programs.

The Telehealth Equity Coalition has developed some recommendations for improving digital literacy, those recommendations can be accessed here. An organization can also work to adopt a digital navigator model. Digital navigators are individuals who address the whole digital inclusion process, including home connectivity, devices, and digital skills, with clients. Navigators can be volunteers or staff at resource serving organizations, such as CBOs.

Privacy

Privacy is an important component of a successful telehealth program, as individuals need a private, quiet space to participate in a tele-health visit. Some individuals may not have a private space for their visits. A consideration for addressing these concerns is by talking with the patient about the spaces that are available to them, such as a library, pharmacy, or community center. These spaces can be possible venues for a private space during a telehealth session.

Self-testing

Self-collection or non-clinic-based testing has emerged as a viable alternative to in-person HIV/STD testing.

The National Coalition of STD Directors has hosted a series of webinars on self-collected HIV and STD testing conducted by mail  that covers the rationale, regulatory environment, examples of testing options, an exploration of the range of possibilities, and discussion of cost as a barrier.

NASTAD has also held webinars on self-HIV testing, as a part of the “Self-Testing Strategies for HIV Testing and PrEP Access” series. This map developed by NASTAD shows states providing free at-home self-testing services, many of which are being offered by CBOs.

To learn more about self-testing, including strategies, testing models, and self-testing program considerations, check-out this toolkit: “Self-Testing: A Strategy to Improve Access to HIV, Viral Hepatitis, and STI Testing”.

Mobile Units

This model encompasses vans, recreational vehicles, and other vehicles that have been repurposed to provide space for clinical services. Mobile units can meet community members in their neighborhood and can provide a whole range of different services, such as HIV and STI screening, PrEP initiation, sexual wellness services and more. 

Miracle of Love, Inc. (MOL), located in Orlando, Florida, owns a mobile testing unit that can be used for HIV prevention education activities as well as HIV screening. The mobile unit includes two air-conditioned private rooms for HIV testing and counseling, as well as storage space. It is driven to a number of events and sites where priority populations may be present. Event organizers can also invite the mobile unit to attend their health fairs, neighborhood festivals, or other community events. This link includes details on how MOL’s mobile unit was detailed.

My Brother’s Keeper, Inc. (Ridgeland, Mississippi)

My Brother’s Keeper, inc. has a driver on staff that picks up and drops off clients for prevention and care service appointments. For clients comfortable using Uber or Lyft services, MBK will pay for ride share services. Ride share services are typically limited as MBK wants to ensure clients are comfortable receiving transportation while not being stigmatized.

Someone Cares Inc. (Marietta, Georgia)

Someone Cares is meeting clients where they are through their mobile unit clinic. Clients can receive a wide range of services, including HIV screening, PrEP, Hormone Replacement Therapy (HRT), and Opioid counseling and treatment!