The RWHAP Best Practices Compilation gathers and disseminates interventions that improve outcomes along the HIV care continuum. Explore the Compilation to find inspiration and new ideas for improving the care of people with HIV. Learn more about the Best Practices Compilation and submit your innovation today for possible inclusion.
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The Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.
Emerging Intervention
People with HIV
Viral suppression
Data utilization approach; Outreach and reengagement activities
UT
HHOME offers mobile HIV primary care, behavioral health care, and connection to housing services to people with HIV experiencing homelessness. A centralized HHOME team acts as a hub to meet clients where they are, refer them to housing and support services, and provide ongoing case management and HIV primary care services. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.
Evidence-Informed Intervention
People who are unstably housed; People with substance use disorder; People with diagnosed mental illness
Retention in HIV medical care; Viral suppression; Beyond the care continuum
Clinical service delivery model; Support service delivery model
San Francisco, CA
Project Vogue provided community-based care coordination, HIV care, and behavioral health services to Black men who have sex with men (MSM) within New York City’s House & Ball community to address the unique cultural barriers that Black MSM experience when trying to access care. Project Vogue participants were linked to behavioral health services as well as to non-clinical supportive services, such as food and housing assistance.
Emerging Intervention
Black gay and bisexual men
Beyond the care continuum
Outreach and reengagement activities; Support service delivery model
New York City, NY
2BU is a case management intervention designed to engage and reengage Black men who have sex with men with HIV into HIV care services. Peer case managers work closely with clients to increase HIV health literacy, troubleshoot accessibility issues to HIV care, and connect clients directly to behavioral health and support services. Clients who participated in 2BU had increased retention in care and viral suppression 12 months after enrollment.
Evidence-Informed Intervention
Black gay and bisexual men; Gay, bisexual, and other men who have sex with men (MSM)
Retention in HIV medical care; Viral suppression
Support service delivery model
Los Angeles, CA
Viviendo Valiente aims to reduce ethnic disparities in HIV care and outcomes by providing culturally responsive services to the Latino/a community, specifically to people of Mexican descent. It is a multi-level intervention, featuring individual-, group-, and community-level activities, that links people to HIV care, offers HIV education and health literacy in group sessions, and promotes community-level testing for HIV and other sexually transmitted infections (STIs). Viviendo Valiente had positive impacts on HIV testing, retention in care, viral suppression, and client satisfaction.
Emerging Intervention
Hispanic/Latina(o/x) people
HIV diagnosis; Retention in HIV medical care; Viral suppression
Outreach and reengagement activities
Dallas, TX
The University of Nebraska Medical Center/Nebraska Medicine (UNMC/NM) Specialty Care Center (SCC) is the largest provider of comprehensive HIV care—including primary and HIV-focused medical services as well as multiple support services—in Nebraska. In March 2020, at the onset of the COVID-19 pandemic, the clinic integrated telehealth into its care delivery model to continue serving patients beyond the clinic structure, and developed algorithms that allowed any team member to quickly identify a patient's eligibility for a telehealth visit. The algorithms include the date of the most recent office visit, stability of HIV disease, most recent viral load and CD4 count, and antiretroviral therapy (ART) refill histories as a proxy for medication adherence. Overall, viral suppression rates remained high for all patients regardless of visit type, indicating that telehealth is a successful alternative to in-person visits for providing HIV care.
Evidence-Informed Intervention
All clients
Viral suppression
Clinical service delivery model; Use of technology and mobile health
Omaha, NE
The Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.
Evidence-Informed Intervention
People with HIV
Linkage to HIV medical care
Data utilization approach
LA
ERASE was developed to address the unique needs of Black MSM. Through an intensive case management intervention, peer case managers provide health education and wellness support, and connect clients to medical and behavioral healthcare. ERASE also offers a physical “safe space” for Black MSM to meet with a case manager, access medical services, or connect with peers. Enrollment in ERASE improved retention in HIV care for clients.
Emerging Intervention
Black gay and bisexual men
Retention in HIV medical care
Outreach and reengagement activities
Oakland, CA
The Enhanced Patient Navigation for Women of Color with HIV intervention uses patient navigators, who are non-medical staff in clinical settings, to reduce barriers to health care and optimize care. The intervention was effective in improving linkage to and retention in care, as well as viral suppression.
Evidence-Informed Intervention
Women of color; Transgender women
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Outreach and reengagement activities; Support service delivery model
Atlanta, GA
Los Angeles, CA
Newark, NJ
The Navigator Case Management intervention helps people with HIV who are incarcerated and are leaving to return to the community. The intervention uses harm reduction, case management, and motivational interviewing techniques to promote healthy behaviors. Enhanced case management including peer support and connection to other needed services both immediately before and after release supports increased linkage to and retention in HIV care for people transitioning to the community from jail.
Evidence-Based Intervention
People who are incarcerated
Linkage to HIV medical care; Retention in HIV medical care
Support service delivery model
San Francisco, CA
