Who’s leading Covid-19 outreach among the homeless? The homeless themselves.

“My story is uniquely my own,” Tina Collins told Mission Local by way of introduction. And that is true: Collins is a 57-year-old mother of four, a longtime Tenderloin resident, and a recovering addict who is currently homeless. 

Collins is also an increasingly sought-after asset during the Covid-19 pandemic: a local who knows her community well. Collins, and others like her, are key to helping the city’s most vulnerable and difficult-to-reach populations. In Collins’ case, her experience with homelessness and her deep ties in the Tenderloin make her uniquely suited to connect with and care for the Tenderloin’s unhoused population. 

Before the pandemic, Collins picked up trash in the mornings as a part of Downtown Streets Team’s work experience program and worked at the Museum of Ice Cream during the day. With the pandemic, Collins has found herself playing a vital role in the UCSF Benioff Homelessness and Housing Initiative’s plan to test the homeless population in the Tenderloin.

The initiative, housed within UCSF’s Center for Vulnerable Populations, is an effort to end homelessness through research-driven solutions that was only a few months old when the pandemic hit. As the virus spread quickly in March, the initiative quickly pivoted to help the city develop a Covid response for San Francisco’s homeless population.

The Benioff Initiative represents another UCSF effort demonstrating to public health officials that the best way to reach isolated communities is to use local assets. UCSF has also used this community-centered approach with the Latino Task Force in the Mission District and with Black churches in Oakland. 

“We do all of our work in partnership, not only with community-based organizations, which are absolutely essential, but most importantly with the community itself,” said Dr. Margot Kushel, director of the UCSF Center for Vulnerable Populations. “I am well aware that any public health response that does not center the voices of people who have lived the experience of homelessness is going to come up with the wrong solution.”

In the early days of the pandemic, no one knew what to do for people experiencing homelessness. 

“What we did know is that there were going to be a lot of people in the homeless population who were really vulnerable to being infected with covid,” said Cynthia Nagendra, executive director of the Benioff Homessness and Housing Initiative.

The homeless population lacked access to PPE and accurate health information, and, because those experiencing homelessness frequently have underlying health conditions, they were more likely to get seriously ill. Before cities implemented alternative housing solutions, covid outbreaks occurred at congregate shelters across the country, including at San Francisco’s MSC South where 92 residents and 10 staff members were infected in April. 

To develop a response, those at the Benioff Initiative needed data. As UCSF had done for the Latinx community in the Mission, the Initiative began a two-part study to test homeless populations in San Francisco’s districts with the highest prevalence of homelessness. In doing so, they prioritized partnerships with local denizens and community-based organizations.

On June 6 and 7, The Benioff Initiative conducted its first testing study in District 10, which includes Bayview-Hunters Point, Potrero Hill, and Dogpatch. The Initiative enlisted locals including Bayview Hunters Point Community Advocates, the Southeast Community Council, and Mother Brown’s Dining Room to learn the best ways to do testing and outreach. The researchers decided on Mother Brown’s as the site for the pop-up. 

In advance, Community Health Outreach Workers – locals hired by the Initiative – did outreach to answer questions and calm fears. The homeless had questions: Would taking a test give them the virus? Would they be forced into isolation if they tested positive? 

Members of the community, like Collins, could assuage those fears and make homeless residents feel better about trusting a bunch of researchers and UCSF medical professionals, Nagendra said.

On the first day of testing, the outreach workers helped get homeless residents to the site. 

The Benioff Initiative tested 488 people in District 10, and the study left the Initiative with a handful of key insights. Most important, they learned early on that being at a fixed site would not easily reach all the people who they wanted to test. They needed the agility of mobile teams. 

The group used that learning in the next stage of its study, on Oct. 10 and 11 in District 6’s Tenderloin and SoMa neighborhoods. 

There too, they tapped into a strong network of groups in the Tenderloin to build out the District 6 study including GLIDE, St. Anthony’s, and Code Tenderloin. 

This time, the initiative switched the emphasis to a mobile testing effort. 

Already, GLIDE, which hosts a community Covid testing site in the Tenderloin, had been using an OPT-IN van program designed to provide mobile testing and outreach for Covid-19, Hepatitis C, and HIV to those living outside. 

GLIDE helped the Benioff Initiative flesh out its mobile-focused testing strategy in District 6.  

The new initiative located its pop-up site at St. Anthony’s, an organization that aims to be a “hub” in the Tenderloin in the same way the Latino Task Force’s Alabama Street Hub is in the Mission, according to Calder Lorenz, senior manager of advocacy at St. Anthony’s. 

The Initiative also used 16 mobile teams during the October study. Each team had at least one Community Health Outreach Worker, a clinician, a phlebotomist to administer tests, an interviewer to administer a survey to participants, and an ethnographer to observe and learn best practices about outreach and testing.

Collins was one of the Community Health Outreach Workers who the Benioff Initiative hired. She led her mobile team to hotspots on the weekend of the study. Her relationships with those being tested were vital.

“I’ve been here for seven years. Everyone knows me,” Collins said. “Workers can be hard to trust because they aren’t always here. I’m always here.”

Those relationships helped the Benioff Initiative reach hundreds more unhoused people than they expected to: the Initiative tested a total of 739 people. 

When the results from the two studies came in, those at the Benioff Initiative were surprised. 

They found one active infection in District 10, and no active infections in District 6. Positivity for antibodies was also low: Kushel estimates 2 to 5 percent of those tested had antibodies in both studies. 

Although the Benioff Initiative is still working to analyze and interpret the results, Kushel has preliminary insights for why infection rates were so low.

“Part of it was that we happened to test at the nadir,” Kushel said. “Had we tested a few weeks before or after, we might have gotten higher positivity rates.”

The fact that the virus is not as easily transmitted outdoors is another explanation. This insight means that unsheltered homeless people are likely less vulnerable to the virus than the high-risk populations in homeless shelters are.

Kushel also credits the work that the communities have been doing since the beginning of the pandemic, such as setting up hygiene stations, promoting and normalizing mask wearing, and distributing PPE.

“I think it’s a testament to these communities and to their local leadership and CBOs, as well as to the strength of the people in them,” she said.

According to Kushel, the goal of these testing studies was always much broader than finding covid infections at the moment the studies occurred. Through the studies’ surveys and interviews, the Initiative aims to make statements about what the homeless population needs, not just in terms of covid testing and resources, but also for a future covid vaccination and other public health efforts. 

“I think a lot of the lessons that we learned will resonate very clearly, not just for covid, but for any public health outreach, whether it’s vaccination campaigns, bringing healthcare services to people, or doing work on sexually transmitted infections and overdose prevention,” Kushel said.

Once the findings from the studies are finalized in about a month, the Benioff Initiative hopes to build a toolkit with best practices for helping homeless populations. The Initiative plans to disseminate this toolkit to public health departments across the country.

As a case manager for the C.A.R.E. Ambassador Program, a collaboration between Downtown Streets Team and Code Tenderloin, Collins is still on the frontlines, helping her community.

“I’m trying to give back,” Collins said. “I just want to be there for the next person.”

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