Health-Harming Legal Needs Identified by People with HIV

Introduction

The movement for health equity – the state in which everyone has a fair and just opportunity to attain their highest level of health [1] – continues to face tremendous challenges both globally and in the United States. For too many people, structural barri- ers to health and well-being are entrenched and for- midable. Meanwhile, the specific barriers confront- ing one population are not the same for another – there is no “one size fits all” approach to health eq- uity advancement [2]. It follows that before design- ing health equity interventions, we must first gain an understanding the of specific barriers impacting spe- cific populations. This analysis is concerned with barriers to care and health for people with HIV (PWH). PWH face unique barriers to health care and optimal health outcomes, including some that can be elimi- nated through legal advocacy [3-6]. Regrettably, most patients are unaware that some barriers to care (and health) may constitute legal rights violations, or may be prevented through proactive legal measures. Current evidence affirms that some HIV care contin- uum outcomes are tied, in whole or in part, to factors enshrined in law and/or public policy [7- 9]. These confirmed barriers have propelled this research. We hypothesize that PWH experience a range of health-harming legal needs (HHLN) [10] and that improved access to legal services can help to resolve these, thereby positively impacting access to care as well as health outcomes. Yet, legal support often is unaffordable or otherwise inaccessible to PWH – as well as to many more people and populations. Mean- while, medical-legal partnership (MLP) strategies, deployed in some healthcare settings since the early

1990s, are not broadly or universally deployed in HIV care settings across the U.S. According to the Administration for Children and Families, an MLP program “integrates civil legal aid services alongside healthcare services to mitigate complex social conditions that may impact the health outcomes of individuals, families, and com- munities” [11]. This paper reports on quantitative and qualitative baseline data from a NIMH-spon- sored cluster randomized controlled trial. Currently underway, OPAHL (Organizational Partnerships for Healthy Living) seeks to understand if and how an MLP intervention improves HIV care continuum outcomes among people receiving care at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania. Key implementation partners include TPAC (The Philadelphia AIDS Consortium, the in- tervention site), Newlands Health (the control site), the Legal Clinic for the Disabled (the legal partner organization), and the Community Collaborative Board (CCB), a body that ensures the study accords with community-based participatory research (CBRP) principles. The two primary aims of the OPAHL trial are to: (1) refine the intervention prototype for implementation with PWH with detectible viral loads; and (2) test the feasibility, acceptability, and preliminary effect sizes of the intervention. The objectives of this paper are to: (1) assess the prevalence and specific types of legal concerns impacting PWH; (2) identify health-harming legal needs that directly or indirectly impact HIV care continuum outcomes among PWH; and (3) document tailored legal interventions and supportive services aimed at addressing health- harming legal needs (HHLN) impacting PWH.

Methods

Description of the OPAHL intervention. The OPAHL intervention is comprised of three compo- nents:

1. Standardized OPAHL training for all part- ners on intersections among social determi- nants of health, legal rights and remedies, HIV care access and health outcomes, and operational imperatives of cross-sector col- laboration; 2. Deployment of a unique screening tool for patients geared to detecting HHLN alongside health-related social needs, as well as a com- panion administration protocol that fosters coordinated hand-off of patients, if they

wish, to the legal partner for an on-site intake interview at the health center; and 3. Access to direct legal services in several le- gal domains through the legal partner organ- ization. Direct legal services take two forms: case handling (legal representation) for indi- vidual patients at no cost, and facilitation of on-site Know Your Rights sessions for the health center community. During the timeframe reflected in this preliminary da- taset, the legal partner conducted two Know Your Rights training sessions at the interven- tion site, including patients and staff, cover- ing “Tenant Rights & Housing Issues” (12/8/22) and “Advanced Planning” (2/9/23). Study methodology Sample and patient eligibility criteria . Under this or- ganizational-level paired matched design, all eligi- ble PWH receiving care at each health center (one assigned to the intervention and the other to the con- trol) were included in the study over a 6-month pe- riod. Patients were eligible to enroll if they met each of the following five criteria: (1) living with HIV (as confirmed by medical record); (2) aged 18 years or older; (3) HIV viral load of more than 200 cop- ies/mL (as confirmed by medical record); (4) willing and able to consent to participate in the trial (includ- ing authorizing access to their medical records at the health center); and (5) no intent to relocate within the 6 months following enrollment. Exclusions in- cluded patients who did not meet the above criteria and individuals who self-reported having been sen- tenced to serve time in state or federal custody, with a sentence to begin within 6 months from proposed enrollment. All research participants were engaged in informed consent procedures enabling collection of data through a longitudinal design. Prospective research subjects were invited to participate in the trial in accordance with all requirements of the Uni- versity of Central Florida Institutional Review Board. Health organization eligibility criteria. The selected health organization: (1) served more than 50 PWH in the year prior to commencing enrollment for the trial; (2) did not facilitate patient access to legal ser- vices either via a co-located partnership or via sys- tematic referrals to external resources; and (3) had capacity, through its EMR, to: (a) collect HIV care continuum outcome indicators; (b) collect compre- hensive primary care medical data; and (c) collect

data on appointments, duration, and types of contact with services; and (4) participated in the trial in ac- cordance with HIPAA-compliant standards. Comparison arm description (Standard of Care). The health organization selected to be the comparison arm only offers patients systematic re- ferral to external legal services. Data sources. The data presented below relates to the second and third components of the OPAHL in- tervention: screening of patients for legal concerns, and access to direct legal services. There are two dis- tinct data sources: (1) screening data from 111 pa- tients in the intervention and control arms, collected

Figure 1. OPAHL resource guide Attorney Case Summaries. It is standard case man- agement practice in the provision of legal services to memorialize a client’s expressed legal concerns. If any form of legal representation is offered or pro- vided (ranging from verbal advice and counsel to di- rect representation in a court or administrative pro- ceeding), at the time the case is closed, it is consid- ered best practice to memorialize the outcome(s) as well as specific services rendered. In the context of this trial, the study team requested that the legal part- ner organization, the Legal Clinic for the Disabled,

between October 20, 2022 and October 26, 2023; and (2) 26 case summaries by the legal provider in the intervention arm, collected between October 22, 2022 and September 29, 2023. We revisit the sample size later in this paper in the context of Limitations . Patient screening data. Screening of participants consisted of flexible, conversational administration of the OPAHL screening instrument (see Figure 1), which poses questions on nearly twenty areas of health-related social need (HRSN) with legal dimen- sions (characterized in the OPAHL protocol as “health-harming legal needs”).

prepare structured “case summaries” with respect to closed cases only (meaning that a case that is still “open” does not yet generate a companion case sum- mary). The standardized Attorney Case Summary form, found below at Figure 2, prompts the dedi- cated attorney to describe key substantive infor- mation with respect to each study enrollee who com- pletes a legal intake interview. From October 20, 2022 through September 29, 2023, the legal partner organization designated 26 cases as “closed” and generated a companion, de-identified Attorney Case Summary for each patient with an associated case.

[REDACTED] MLP Attorney Case Summary Member Name:

Number of Individuals in Member Household:

Keystone First /Medicaid IDs:

LCD Client Name:

LCD ID:

Referral Information:

Date of Intake:

Presenting Needs (At Time of Intake):

Total # of Successful Interventions by LCD:

Case Summary:

Case Closure Date:

Outcome / Resolution:

Outstanding issues:

Attorney name:

Date of completion:

Figure 2. Attorney case summary form Data analysis – Patient Screening. Quantitative data generated from the screening process was analyzed using basic, descriptive statistics to determine fre- quency and burden (proportion) of legal barriers for study participants. Data analysis – Case Summaries. Case summaries were coded using standard open qualitative methods to identify major themes and patterns. This approach allows for a nuanced understanding of the complex legal needs experienced by PWH. Two members of the research team, who are licensed attorneys, inde- pendently reviewed and analyzed the case summar- ies. The involvement of licensed attorneys ensures that the analysis is grounded in legal expertise while maintaining research integrity by excluding legal partner organization staff from the data analysis pro- cess. Given the high prevalence of positive screens in specific domains, we focused our qualitative anal- ysis on Personal Planning/Advanced Care Planning and Living Situations. These areas were chosen due to their significant representation in patient-reported

concerns, as illustrated in Figures 3 and 4. "Other"- related Attorney Case Summaries were excluded from this analysis due to the small numbers and the difficulty in forming meaningful hypotheses from such limited data. To further enhance the depth of our analysis, we em- ployed a rapid qualitative analysis approach. This method involves the expedited coding and synthesis of qualitative data to quickly generate insights while maintaining rigor and validity. Rapid qualitative analysis is particularly useful in health services re- search where timely results are crucial for informing practice and policy [12]. Our goal in this qualitative review was to illuminate the specific features of con- cerns expressed by PWH regarding Personal Plan- ning/Advanced Care Planning and their Living Situ- ations. By focusing on these domains, we aimed to uncover detailed insights into the legal challenges faced by PWH and how these impact their overall health and well-being. This analysis provides a richer context for understanding the intersection of

legal and health needs, ultimately informing targeted interventions to improve the HIV care continuum [13].

Results

Descriptive data on participants. This study pro- vides descriptive quantitative baseline screening data from 111 patients in the intervention and con- trol arms, and qualitative data from 26 case summar- ies generated by an attorney providing legal services in the intervention context. Barriers to care and health reported by PWH. En- rollment for the study began on October 20, 2022. By October 26, 2023, the study had enrolled 111 pa- tients. As of that date, self-reported “positive screens” among enrollees – tied to administration of

or a family member) (n = 21)  Transportation to Appointments (n = 20)

the OPAHL screening tool – were as follows in Ta- ble 1 (tracking the exact sequence of questions in the screening instrument). The top five (5) categories of concern as classified by the OPAHL Resource Guide and reported by study enrollees were:

 Personal Planning, Advanced Care Planning

(health care, financial power of attorney, liv- ing will, etc.) (n = 50)  Other (n = 26)  Unsafe Housing or Repairs (n = 23)  Emotional or Behavioral Concerns (for you

re-analyzed the screening results, now combining the ninth and tenth questions – regarding Unsafe Housing or Repairs and Eviction or Threat of Losing Home – as a single category, the prevalence data shifted as reflected below in Figure 4. By this mod- ified analysis, Living Situation is the second-highest patient-reported category of concern (n = 38).

consolidation of "living situation" categories Barriers to Care and Health Observed in Attorney Case Summaries. From October 20, 2022 through September 29, 2023, the legal partner designated 26 cases “closed” and generated a de-identified com- panion Attorney Case Summary for each subject with an associated case. At this preliminary stage of study enrollment, implementation, and data analy- sis, we opted to review any raw qualitative data from the Attorney Case Summaries that fell within three screening domains: (1) Personal Planning, Ad- vanced Care Planning (n = 5 related Attorney Case Summaries); (2) Unsafe Housing or Repairs (n = 4 related Attorney Case Summaries); and (3) Eviction

N = positive screens

or Threat of Losing Home (n = 1 related Attorney Case Summary).

We selected for analysis only Personal Plan- ning/Advanced Care Planning and the consolidated, CMS-aligned category of Living Situation (reflect- ing Unsafe Housing or Repairs and Eviction or Threat of Losing Home ) because of their high prev- alence in patient-reported positive screens, per Fig- ures 3 and 4, above. We excluded “Other”-related qualitative data due to challenges in developing hy- potheses based on such small numbers. Our goal in this qualitative review was to illuminate specific fea- tures of concerns expressed by PWH regarding Per-

sonal/Advanced Care Planning and their Living Sit- uation. We present this detailed information in Ap- pendix 1, including:

 Screening topics prioritized for analysis and

tied to Figure 1 (OPAHL screening tool).  De-identified excerpts from Attorney Case

Summary forms tied to the prioritized screening domain.  Qualitative analysis focused on key words,

observations, and themes appearing in the forms.

Discussion

Key result: Prevalence of Personal Plan- ning/Advanced Care Planning and Living Situation Legal Concerns Disclosed by PWH . Participants ex- pressed greatest concern with respect to Personal Planning/Advanced Care Planning, a domain that encompasses a range of high-stakes decisions in- volving one’s financial, medical, and related affairs and autonomy. This domain generated significantly higher positive screens (n = 50) than that with the second-highest number of positive screens. Paired with the Attorney Case Summary data, we know that five (5) study enrollees with questions about this domain sought and received legal services at no cost relating to: power of attorney (a form of legal decision-making authority); wills; advanced healthcare directives, including living wills; and fi- nancial authority designations, such as naming of bank account beneficiaries. The substantial rate of positive screens in this do- main of legal concern can be attributed to several in- terconnected factors. A key explanation lies in the characteristics of the study participants. Most of them reside in underserved communities in Philadel- phia, where systemic barriers, such as limited access to legal services, are pervasive. These communities also contend with rapid gentrification, which exac- erbates social and structural inequalities. Gentrifica- tion often displaces long-term residents, drives up housing costs, and intensifies economic instabil- ity—all of which compound the legal and health care challenges faced by individuals in these communi- ties [15-17]. These structural inequities shape partic- ipants’ perspectives on end-of-life care and influ- ence their broader health care decision-making pro- cesses, creating a landscape where legal concerns are both prevalent and complex. Another significant factor is the culture of care at the health clinic participating in this study. The clinic fosters a high-trust, patient-centered environment

that prioritizes the well-being and comfort of its pa- tients. In such a setting, people with HIV (PWH) are more likely to feel safe disclosing highly sensitive information about their life goals, health concerns, and legal needs. This culture of trust cultivates open, meaningful conversations, enabling patients to share issues they might withhold in less supportive envi- ronments [18, 19]. The supportive dynamic between patients and health care providers likely explains the elevated rate of positive screens, as patients feel en- couraged to discuss their full spectrum of concerns. The Know Your Rights training conducted at the in- tervention site also played a pivotal role. These workshops were not limited to the clinic’s patient population, but were extended to the broader com- munity through targeted outreach efforts. This pro- active approach helped raise awareness and ex- panded the reach of the training, offering accessible resources and empowering individuals with knowledge about their legal rights. By fostering trust and engagement among community members, these initiatives likely influenced participants’ willingness to recognize and disclose legal concerns during the screening process. It is also important to consider the historical context. Many PWH have experienced alienation, stigma, or discrimination in health care settings, which has of- ten inhibited full and open communication [20-23]. This historical mistrust underscores the significance of environments that actively counteract these pat- terns. A clinic culture that fosters trust and respect, combined with community-based educational ef- forts, creates the conditions necessary for individu- als to voice concerns that might otherwise remain unspoken. Together, these factors—participant de- mographics, the clinic’s high-trust environment, community-wide outreach efforts, and the broader historical context—help explain the substantial rate of positive screens in this domain. Addressing these issues holistically highlights the importance of inte- grating structural, cultural, and community-level in- terventions to enhance both legal and health care outcomes. In addition to these structural dynamics, additional variables may be operating. First, it is likely that PWH have had conversations about mortality with clinicians, family and friends in ways that people not living with chronic serious illness have not. They may be more attuned to questions about end-of-life decision-making than others. (Indeed, in one in- stance, a participant raised questions about funeral planning.)

Second, estate planning legal services are expensive and often financially out of reach. In addition, the complex vocabulary (words like “estate,” “probate,” and “beneficiaries”) can pose barriers to defining one’s question(s) and finding responsive resources. This is consistent with literature documenting that those living in low-opportunity areas have lower odds of conducting advanced care planning com- pared with those in neighborhoods with high socio- economic status [24]. Our study participants were recruited and engaged from an urban neighborhood in a state (Pennsylvania) that ranks 34 th for “Attor- ney Access” nationally (n = 52, including 50 states, Puerto Rico, and the District of Columbia) [25]. Finally, practically speaking, nearly all adults in the U.S. would benefit from proactive advice on finan- cial, medical, and end-of-life decision-making; mor- tality is universal and this kind of anticipatory plan- ning is a valuable tool at a population level (as op- posed to a legal response to a legal violation). That their Living Situation was reported to be a con- cern by a substantial number of study participants was not surprising to the research team. Barriers to affordable, habitable housing are a well-documented national phenomenon in the U.S [26]. Meanwhile, there is a substantial evidence base describing the nexus between housing instability and access to care as well as poor health outcomes, both generally [27] and for PWH, for whom the rigors of HIV care can be easily disrupted by housing instability and home- lessness [28]. Key result: Prevalence of “Other” Legal Concerns Disclosed by PWH. Significantly, the second-high- est domain of positive screens was “Other.” As de- scribed above, a non-trivial number of the free-text responses submitted under the “Other” domain aligned with existing topics contained in the screen- ing tool, specifically Personal Planning/Advanced Care Planning, as well as Eviction or Threat of Los- ing Home and Unsafe Housing or Repairs . We hy- pothesize that this is a byproduct of several possible factors:

 The conversational nature of the screening

encounter (an intentional feature of the study design intended to promote trust- and rela- tionship-building between FQHC staff and patients) may undermine the precision with which positive screens are documented. The intervention’s commitment to patient-cen- tered screening administration – as opposed to a “check-box, check-out” encounter – may

prompt staff to record patient concerns in de- tail under “Other” as opposed to classifying them under an existing screening topic.  Patients may not see (or hear) their experi-

ences reflected in the language of the OPAHL screening instrument and its catego- ries. Therefore, “Other” may be checked to honor their individual expression of their concerns.  The boundary line between health-related

social needs and health-harming legal needs is complicated. Patients may not interpret their goals and needs to be “legal” in nature; conversely, they may perceive the screening encounter to be interested only in what is fundamentally “legal.” This may impact when and whether “Other” is selected rather than indicating a positive screen for an exist- ing, specific domain. We look forward to additional data analysis that can shed light on future screening psychometrics strate- gies once the study concludes and all data is availa- ble. Key result: Impact of Legal Services Provision on Personal Planning/Advanced Care Planning Con- cerns and Living Situation-aligned Legal Concerns Disclosed by PWH. Analysis of the qualitative data contained in the Attorney Case Summary forms led to identification of several types of legal services that helped to eliminate a patient-reported legal con- cern. In the Personal Planning/Advanced Care Plan- ning context, these services included, but were not limited to:

 Advising a PWH on the value of a power of

attorney document and preparing a tailored one for them.  Advising a PWH who was confronting mor-

tality-related concerns on the complex legal considerations relating to preparation of a will, planning for funeral expenses, and pre- paring to relinquish custody of a grandchild.  Advising a PWH on the complex legal con-

siderations relating to receipt of a personal injury settlement, preparation of a will, mod- ification of bank account beneficiary desig- nations, and potential implications for eligi- bility for SSA-administered benefits.  Advising a PWH on the complex legal con-

siderations relating to estate planning (prep- aration of a will specifically) and eligibility for SSDI benefits in a re-certification con- text.

 Advising a PWH on the range of advanced

healthcare directives available to them and preparing a tailored advanced healthcare di- rective for them. Key result: Impact of Legal Services Provision on Living Situation Concerns Disclosed by PWH. The data also identified several types of legal services that helped (or could help) to elim- inate a patient-reported legal concern. These ser- vices included, but are not limited to:  Advising a PWH on their legal rights to ter-

minate (and/or not renew) a rental agreement and preparing a letter that the individual could transmit to their landlord to document the assertion of those rights.  Advising a PWH on their legal rights (both

in general and as an immigrant) in connec- tion with a complex set of legal concerns, in- cluding risk of eviction due to non-payment of rent, housing conditions that may violate applicable sanitary/habitability codes, and eligibility for public benefits that could bol- ster household income.  Advising a PWH on their legal rights as a

tenant to seek remediation of unsanitary/un- inhabitable conditions in their rental unit and offering to draft an advocacy communication to the landlord. With respect to the latter two Key Results, these pos- itive impacts were generated through a study design that guaranteed basic legal support for all interven- tion subjects. However, this does not reflect reality for most PWH in the U.S. Securing legal services in the U.S. is frequently constrained by, among other things, financial cost, transportation and language barriers, and uncertainty about the value of legal re- sources [29]. In the context of HIV care, the data presented here suggest that an MLP strategy can be an effective access-to-justice promotion tool for PWH. Other access-to-justice levers that could be consid- ered or integrated with MLP for PWH encompass a wide array of innovative and community-centered approaches. Legal services organization initiatives, which often provide targeted support to underserved populations, can help bridge the gap for PWH who face barriers to traditional legal services. Pro bono programs (where attorneys volunteer their services) and low bono programs (offering reduced-fee legal services) are another mechanism to increase access to justice for PWH. These programs can be tailored to address the unique legal needs of this population,

such as assistance with housing instability, discrim- ination cases, or navigating healthcare benefits. Sliding-scale legal fee structures are another tool, enabling legal service costs to be adjusted based on the client’s income and financial circumstances. Ad- ditionally, charitable assistance funds dedicated to supporting legal services for PWH can provide fi- nancial grants or subsidies to cover legal fees, ensur- ing that cost is not a barrier to accessing necessary legal help. These strategies, especially when inte- grated into an MLP framework, can create a com- prehensive ecosystem of support for PWH. Relationship to prior studies. This is one of the first rigorous studies that analyzes (a) the prevalence of barriers to care/health for PWH that may be amena- ble to legal advocacy; and (b) the ways in which le- gal concerns impact access to care and health out- comes for PWH. While related studies have been conducted in other chronic disease contexts and with other marginalized populations [30], this study in- volving PWH is a pioneering effort. Limitations and efforts to address/mitigate. The study has several limitations. First, it was con- strained by a relatively small sample size, which may limit the generalizability of the findings to broader populations of PWH. The results may not fully represent the diversity of, or predominance of, legal concerns among the larger community of PWH. Second, participants were recruited from only two healthcare facilities, potentially introducing se- lection bias. Third, the study’s timeframe may not be sufficient to capture the long-term effects of legal in- terventions on HIV care continuum outcomes. Lon- gitudinal data over an extended period could provide a more comprehensive understanding of the sus- tained impact of legal services as a care enhance- ment. Fourth, the study relied on self-reported data regarding legal concerns. This could introduce recall bias or social desirability bias, where participants might underreport or overreport information. Fifth, resource limitations might have impacted the scope of the study, potentially restricting the depth of legal interventions or comprehensive data collection methods that could have been employed. Implications for practice, policy, and research. These results point to the importance of future re- search exploring how Personal Planning/Advanced Care Planning and Living Situation challenges oper- ate to present barriers to health care and positive health outcomes for PWH. The results also point to the likely wisdom of deeper investment in strategies

that can mitigate or eliminate barriers to patient-cen- tered personal/advanced care planning and housing stability for PWH. In addition, more granularly, the results indicate that further refinement of the OPAHL Resource Guide (screening tool) and OPAHL Attorney Case Summary form – both in practice and in research contexts -- likely can illumi- nate data that would be valuable to future interven- tion design, implementation, efficacy, and cost-ef- fectiveness. Analysis of the OPAHL Resource Guide (Figure 1) – the study’s non-validated screening instrument for both health-related social needs (HRSN) and health- harming legal needs (HHLN) – suggests that the tool may be highly sensitive for detecting health-related social needs (HRSN), but insufficiently sensitive and specific for health-harming legal needs (HHLN), resolution of which requires trained attor- neys as opposed to other para/professional actors. Future practice, policy, and research will benefit from identification of – or development of – sensi- tive and specific screening tools to detect HHLN. Analysis of the Attorney Case Summaries confirms that scarce and valuable legal services were deliv- ered to study participants in a range of high-stakes contexts. This raises yet more questions to be ex- plored. In the OPAHL intervention context, a sum- mary form only can be generated after the following events have occurred: patient enrollment, screening, detection of positive screens, offer of legal service referral, acceptance of said referral invitation, legal intake interview, and case closure by the attorney. The above conditions are a floor of legal support fa- cilitation, not a ceiling. Many types of legal services can be provided between the legal intake interview phase and case closure. Yet, as a data collection mechanism, the Attorney Case Summary form does not render visible when and how actual legal ser- vices were provided; the form merely confirms that some type of legal service was provided. Refining this form could promote future learning regarding, for instance:

 The time and effort involved in legal inter-

vention, overall and broken down by func- tion;

 Whether the legal intake interview was pri-

marily a “legal diagnostic” encounter, or whether it also functioned as an active legal services encounter. Historically, legal intake interviews have not been recognized a priori

as a form of legal service. Often, the inter- view enables discernment of the specific le- gal questions or problems the individual may have, and whether the intaking organization has the relevant expertise and capacity. Given general resource constraints in both health care and public interest law, collecting data on how this interview encounter is lev- eraged to benefit patients/clients could have powerful implications for future cost-benefit studies. Another question raised by the qualitative analysis relates to the amenability of the participants’ legal concerns to legal resolution based on state or terri- tory of residence. It is possible the estate planning successes and housing advocacy strategies reflected in Appendix 1 were linked to favorable state laws specific to Pennsylvania.

Conclusion

This study provides essential baseline data on barri- ers to care and health experienced by PWH that may be addressed through legal advocacy. By examining quantitative screening data from 111 participants across both intervention and control arms, and qual- itative data from 26 case summaries by legal provid- ers in the intervention arm, the study highlights a range of concerns experienced by PWH. The OPAHL screening data identified Personal Planning/Advanced Care Planning as the most prev- alent concern among participants, followed by Liv- ing Situation. These findings underscore the sub- stantial challenges faced by PWH in maintaining safe and stable housing and planning for complex medical, financial, and familial decisions. They also highlight the structural context in which PWH at- tempt to access care and improve their health out- comes. These insights point to the need for individ- ual-level access to legal services in health clinics, as well as larger-scale policy and system changes that promote greater access to essential resources like housing and planning support. Qualitative analysis of OPAHL Attorney Case Sum- maries revealed that legal services significantly sup- ported PWH in addressing concerns related to Per- sonal Planning/Advanced Care Planning and Living Situations. Legal services included drafting powers of attorney, wills, and advanced healthcare direc- tives, and providing tailored legal advice on estate planning and housing issues. The findings emphasize the importance of integrat- ing legal support into comprehensive care for PWH. Future research should further explore key domains

of health-harming legal needs (HHLN) and develop refined screening instruments and data collection methods to better detect HHLN and understand the

value of various legal services. See Table 2, below, for a summary of significance and contribution.

EXCERPTS AND ANALYSIS OF ATTORNEY CASE SUMMARY DATA IN THREE SCREENING DO- MAINS COMPRISING TWO ANALYTIC CATEGORIES (PERSONAL PLANNING, ADVANCED CARE

PLANNING; LIVING SITUATION) Screening

De-identified Excerpts from

Topic

Attorney Case Summary

Themes Personal Planning, Advanced Care Plan- ning

Presenting Needs (At Time of Intake): “Power of Attorney” Issues Addressed []: “Power of Attorney” Case Summary: “Cl[ient] presented looking for a power of attorney. [Attorney] advised cl[ient] on advanced planning documents and implications of executing the power of attorney for cl[ient]'s needs.” Outcome/Resolution: “[Attorney] assisted cl[ient] w/ drafting and executing power of attorney.” Outstanding Issues: “None”

Presenting Needs (At Time of Intake): “Cus- tody, [] Wills” Issues Addressed []: “Wills” Case Summary: “Cl[ient] presented w/ questions on relinquishing . . . custody of . . . grand[child] and advanced planning.” Outcome/Resolution: “[Attorney] advised cl[ient] on custody modifications/wills and funeral plan- ning.” Outstanding Issues: “Custody”

Presenting Needs (At Time of Intake): “Wills” Issues Addressed []: “Wills” Case Summary: “Cl[ient] recently received a per- sonal injury / accident settlement for [substantial sum]. Cl[ient] wanted advice on advanced plan- ning / drafting a will. [Attorney] advised cl[ient] on probate and non-probate assets; and naming beneficiaries to bank accounts. [Attorney] further directed cl[ient] to speak w/ a financial advisor / the bank about managing the money. [Attorney] advised cl[ient] on [implications for current] SSA benefits. [Attorney] advised cl[ient] to wait on drafting a will until [they hold] the assets. Cl[ient] confirmed [they have] an advanced healthcare di- rective in place through [their] PCP.” Outcome/Resolution: “[Attorney] provided ad- vice. Cl[ient] to follow-up w/ [Attorney] for addi- tional advice if necessary.” Outstanding Issues: “None”

Presenting Needs (At Time of Intake): “[SSDI], [] Wills” Issues Addressed []: “[SSDI], [] Wills” Case Summary: “Cl[ient] presented w/ questions on SSDI and estate planning. [Attorney] advised

Appendix 1.

Analysis: Key Words, Observations, and

 “Power of attorney”  “Advised client”  “Advanced planning documents”  “Implications of executing the power of at- torney for cl[ient]’s needs”  “Drafting and executing power of attorney”  When case was closed, Client was equipped with new, tailored legal resource (power of attorney).

 Custody and related modifications  Wills  “Relinquishing . . . custody of . . . grand[child]” and phenomenon of grandpar- ents raising minor grandchildren  Funeral planning  When case was closed, Client was equipped with specific legal advice.

 Wills  “Personal injury”, related monetary settle- ment  “Advanced planning”  “Drafting a will”  “Probate and non-probate assets”  “Naming beneficiaries to bank accounts”  Consulting a financial advisor  “[Implications for current] SSA benefits”  Holding assets  “Advanced healthcare directive”  “Provided advice”  When case was closed, Client was equipped with specific legal advice and invited to re- engage with Attorney if desired.

 SSDI (Social Security Disability Insurance)  Wills  “Estate planning”  “Advised cl[ient] on SSA benefits gener- ally” and on “estate planning documents generally”

cl[ient] on SSA benefits generally. Cl[ient] has not had a disability determination yet. [Attorney] ad- vised cl[ient] to contact [Attorney] if [they are] de- nied benefits to discuss the redetermination / ap- peal process. [Attorney] advised cl[ient] on estate planning documents generally. Cl[ient] to follow up w/ [Attorney] when she is ready to draft and execute documents.” Outcome/Resolution: “Cl[ient] did not follow up w/ [Attorney].” Outstanding Issues: “[SSDI], [] Wills”

Presenting Needs (At Time of Intake): “Living will - Advanced directive” Issues Addressed []: “Living will - Advanced di- rective” Case Summary: “Cl[ient] presented looking for a healthcare power of attorney/living will. [Attor- ney] advised cl[ient] on advanced planning docu- ments and benefits of executing the advanced healthcare directive.” Outcome/Resolution: “. . . [A]ssisted cl[ient] w/ drafting and executing cl[ient’s] advanced healthcare directive.” Outstanding Issues: “None”

Presenting Needs (At Time of Intake): “Non-re- newal of lease” Issues Addressed []: “Non-renewal of lease” Case Summary: “[Cl]ient presented with ques- tions about how to terminate [their] lease and leave property b/c of ongoing habitability issues.” Outcome/Resolution: “[Attorney] advised cl[ient] on notice requirements to not renew lease. [Attor- ney] ghost wrote non-renewal letter for cl[ient] to send to [Landlord].” Outstanding Issues: “None”

Unsafe Housing or Repairs (falls under umbrella of CMS’s Liv- ing Situa- tion do- main)

 “Section 8”  “Looking to sue individual / agency”  “Voucher / placement”  “[Un]inhabitable property”  Phenomenon of legal partner organizations identifying “conflict[s]” of interest that can impact ability to offer legal services  When case was closed, Client had not re- ceived any legal services due to conflict sit- uation; unclear whether alternative resource (referral) information was supplied.  Summary indicates Client had “no[]” out- standing issues at time case was closed, but technically their presenting question was not resolved. Presenting Needs (At Time of Intake): “Other Miscellaneous” Issues Addressed []: “Other Miscellaneous”

Presenting Needs (At Time of Intake): “Section 8 Other” Issues Addressed []: “Section 8 Other” Case Summary: “Cl[ient] presented . . . looking to sue individual/agency who secured cl[ient] housing voucher/placement at [un]inhabitable property.” Outcome/Resolution: “[Attorney] advised cl[ient] [that legal partner organization] had a conflict and could not provide further advice.” Outstanding Issues: “None”

 “Disability determination” and relationship to pending SSDI application or appeal  “Redetermination / appeal process”  “Draft and execute documents”  When case was closed, Client was equipped with legal advice and invited to re-engage with Attorney if desired; Case closed be- cause Client did not “follow up” with Attor- ney.

 “Living will”  “Advanced directive”  “Healthcare power of attorney”  “Advised cl[ient] on advanced planning documents and benefits of executing the ad- vanced healthcare directive”  “Drafting and executing cl[ient’s] advanced healthcare directive”  When case was closed, Client had new, tai- lored legal resource (advanced healthcare directive).

 “Non-renewal of lease”  Termination of lease  “Habitability issues”  “[Attorney] advised cl[ient] on notice re- quirements to not renew lease.”  “[Attorney] ghost wrote non-renewal letter for cl[ient] to send to [Landlord]”  Ghost-writing phenomenon as part of legal advocacy

 Intersections among immigration status, benefits eligibility, employment status, and housing expenses

Case Summary: “Cl[ient presented looking for help w/ [immigration and benefits] b/c cl[ient] is unemployed and unable to work b/c of [chronic se- rious illness]. Cl[ient] is late on paying rent b/c he is sick. Cl[ient]'s wife is working and meeting the obligation but a few times the rent has been late. L[andlord]has threatened cl[ient] w/ eviction b/c of late payments and requests for repairs. Cl[ient] has leaks, crumbing facade and foundation. There are issues with the patio and gas system. [Attor- ney] advised cl[ient] to call [specific resource] to inspect re repair issues. L[andlord] does not have an active rental license. Cl[ient] requested [Attor- ney] draft a demand letter to L[andlord] to make the repairs. Outcome/Resolution: [Attorney] advised meeting w/ [a specific resource]. Cl[ient] already met w/ [that resource] and it could not provide . . . help. Cl[ient] [is confronting immigration challenges]. [Attorney] advised cl[ient] [that someone lacking] . . . permanent resident status . . . does not qualify for SNAP or disability benefits. [Attorney] advised cl[ient] to call [specific resource] to inspect re re- pair issues. [Attorney] advised cl[ient] on implica- tions re an eviction b/c L[andlord] does have rental license. [Attorney] provided cl[ient]housing and food resources and the contact info for [specific resource]. Cl[ient] withdrew / did not return.” Outstanding Issues: “None”

Presenting Needs (At Time of Intake): “Private [Landlord/Tenant] Repairs” Issues Addressed []: “ Private [Landlord/Tenant] Repairs” Case Summary: “ . . . [H]abitability issues at . . . unit. Cl[ient] has a subsidy through . . . b/c of . . . HIV status. Cl[ient] has issues with mold and ants. Cl[ient] first identified the mold issue in 2021 but the issue is ongoing. Cl[ient] has mold on the kitchen ceiling and in her bathroom. L[andlord] made quick fixes by covering it up w/ spackle and a tape strip. Cl[ient] also has ants. The ants were coming out of the ceiling near the light fixture in the kitchen. L[andlord] also covered hole w/ spackle. Now cl[ient] has ants in the bathroom. Cl[ient] paid to have extermination services every 6 weeks in 2021 and 2022. Cl[ient] is no longer paying for the service and thinks [Landlord] should be responsible. [Attorney] advised on ten- ants' rights, [specific resource], withholding rent, and writing a demand letter.” Outcome/Resolution: “Cl[ient] did not follow-up to provide lease.”

 "Late on paying rent”, “a few times the rent has been late”  “L[andlord] has threatened . . . eviction b/c of late payments and requests for repairs.”  Phenomenon of non-payment of rent as a basis for landlord-threatened or -initiated eviction actions  “Leaks, crumbling façade and foundation”  “Issues with patio and gas system”  Attorney encouraged Client to activate a rental unit inspection process.  Question of whether Landlord has “rental li- cense”  “Demand letter”  Attorney recommended Client connect with an additional community resource; Client already had communicated with them and did not receive the support they sought.  “[Attorney] advised cl[ient] on implications re an eviction”  At time case was closed, “Cl[ient] withdrew / did not return.” What exactly does this mean?  Labeled “Other Miscellaneous” but pa- tient’s reported concerns are related to Im- migration, Benefits, and Housing (Living Situation) domains, minimally.

 “Private” and the phenomenon of some liv- ing situations involving private-market landlords as opposed to other types of hous- ing/shelter providers  “Habitability issues”  “Subsidy”  “Mold issue” in kitchen and bathroom  “Ants” in bathroom  Costs of extermination services; who should bear them  “[Attorney] advised on tenants' rights, [spe- cific resource], withholding rent, and writ- ing a demand letter.”  Attorney apparently had asked Client to supply a copy of the lease to inform the next stage of potential legal services.  At time case was closed, evidently “Cl[ient] did not follow up to provide lease” and therefore additional legal services could not be offered.

Outstanding Issues: “Private [Landlord/Tenant] Repairs” Eviction or Threat of Losing Home (falls under umbrella of CMS’s Liv- ing Situa- tion do- main)

Presenting Needs (At Time of Intake): “Other Miscellaneous” Issues Addressed []: “Other Miscellaneous” Case Summary: “Cl[ient presented looking for help w/ [immigration and benefits] b/c cl[ient] is unemployed and unable to work b/c of [chronic se- rious illness]. Cl[ient] is late on paying rent b/c he is sick. Cl[ient]'s wife is working and meeting the obligation but a few times the rent has been late. L[andlord]has threatened cl[ient] w/ eviction b/c of late payments and requests for repairs. Cl[ient] has leaks, crumbing facade and foundation. There are issues with the patio and gas system. [Attor- ney] advised cl[ient] to call [specific resource] to inspect re repair issues. L[andlord] does not have an active rental license. Cl[ient] requested [Attor- ney] draft a demand letter to L[andlord] to make the repairs. Outcome/Resolution: [Attorney] advised meeting w/ [a specific resource]. Cl[ient] already met w/ [that resource] and it could not provide cl help. Cl[ient] [is confronting immigration challenges]. [Attorney] advised cl[ient] [that someone lacking] . . . permanent resident status . . . does not qualify for SNAP or disability benefits. [Attorney] advised cl[ient] to call [specific resource] to inspect re re- pair issues. [Attorney] advised cl[ient] on implica- tions re an eviction bc L[andlord] does have rental license. [Attorney] provided cl[ient]housing and food resources and the contact info for [specific resource]. Cl[ient] withdrew / did not return.” Outstanding Issues: “None”

 Intersections among immigration status, benefits eligibility, employment status, and housing expenses  "Late on paying rent”, “a few times the rent has been late”  “L[andlord] has threatened . . . eviction b/c of late payments and requests for repairs.”  Phenomenon of non-payment of rent as a basis for landlord-threatened or -initiated eviction actions  “Leaks, crumbling façade and foundation”  “Issues with patio and gas system”  Attorney encouraged Client to activate a rental unit inspection process.  Question of whether Landlord has “rental li- cense”  “Demand letter”  Attorney recommended Client connect with an additional community resource; Client already had communicated with them and did not receive the support they sought.  “[Attorney] advised cl[ient] on implications re an eviction”  At time case was closed, “Cl[ient] withdrew / did not return.” What exactly does this mean?  Labeled “Other Miscellaneous” but pa- tient’s reported concerns relate to Immigra- tion, Benefits, and Housing ( Living Situa- tion ) domains, minimally.