The New York City HIV Care Coordination Program is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. Multiple evaluations of the program consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.
Evidence-Based Intervention
People with a new diagnosis of HIV; People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Clinical service delivery model; Outreach and reengagement activities; Support service delivery model; Systems/structural interventions
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 justice involved
Linkage to HIV medical care; Retention in HIV medical care
Support service delivery model
Project nGage is a support intervention approach that offers participants an initial 90-minute session with a social work interventionist and a participant support confidant to develop a tailored care and support plan. The social work interventionist then offers four follow-up sessions to each participant to discuss progress on the care and support plan. Project nGage was evaluated in a randomized controlled trial from 2012 to 2015: participants in the intervention were more likely to have at least three HIV primary care visits in the last 12 months than those who received usual care.
Evidence-Based Intervention
Gay, bisexual, and other men who have sex with men (MSM); Black gay and bisexual men; Youth ages 13 to 24; Young adults ages 25 to 34
Retention in HIV medical care
Support service delivery model
This intervention to rapidly re-house people with HIV was implemented at multiple New York City shelters and was associated with significant improvements in viral suppression.
Evidence-Based Intervention
People who are unstably housed
Viral suppression; Beyond the care continuum
Support service delivery model
The RWHAP Part F SPNS program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.
Evidence-Based Intervention
People who are unstably housed
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression; Beyond the care continuum
Support service delivery model
Pasadena, San Diego County, San Francisco, CA
New Haven, CT
Jacksonville, FL
Cumberland, Hoke, Harnett, Johnston, and Sampson Counties, NC
Multnomah County, OR
Dallas and Harris Counties, TX
Five clinics implemented Tailored Motivational Interviewing (TMI) to better serve young people with HIV as part of a RWHAP Part F SPNS initiative. Motivational interviewing is a well-documented approach to engage youth in care and facilitate behavior change in a variety of contexts. Clients participating in TMI received integrated HIV medical care and TMI, and demonstrated improved engagement in care and health outcomes.
Evidence-Based Intervention
Support service delivery model
Los Angeles, CA
Ft. Lauderdale, FL
Baltimore, MD
Detroit, MI
Philadelphia, PA
LINK LA is a 12-session, 24-week peer navigation intervention for people with HIV who are scheduled to be released from incarceration. LINK LA peer navigators focus on behavioral changes that promote medication adherence and retention in care, while providing social support and facilitating communication with medical providers. LINK LA showed improvements in linkage to and retention in HIV care and viral suppression among people with HIV re-entering the community after incarceration.
Evidence-Based Intervention
People who are justice involved
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Outreach and reengagement activities; Support service delivery model
Seeking Safety helps people who have experienced trauma and/or substance use disorder gain safe coping skills through a flexible 12-session intervention. The University of California, San Diego Mother Child Adolescent HIV Program and the Multicultural AIDS Coalition implemented Seeking Safety as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Participants had higher rates of retention in care and viral suppression after 12 months of the intervention.
Evidence-Based Intervention
People with a history of trauma; People with substance use disorder
Retention in HIV medical care; Viral suppression
Support service delivery model
Cognitive Processing Therapy (CPT) is an evidence-based, cognitive behavioral treatment for posttraumatic stress disorder. Through individual or group sessions of CPT, clients learn to recognize and challenge unhelpful thoughts and beliefs related to trauma. Positive Impact Health Centers and Western North Carolina Community Health Services implemented CPT as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017 to 2021. While not statistically significant, CPT participants had increased engagement in care and retention in care from enrollment to 12 months.
Evidence-Based Intervention
People with a history of trauma
Retention in HIV medical care
Support service delivery model
Decatur, GA
Duluth, GA
Marietta, GA
Asheville, NC
Tailored Motivational Interviewing (TMI) delivers brief motivational interviewing counseling sessions customized to encourage people with HIV to engage in HIV care, take HIV medications as prescribed, and improve other health-related behaviors. Three sites implemented TMI as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017 to 2021. Clients who participated in TMI had significant improvement in engagement in care, prescription of antiretroviral therapy, retention in care, and viral suppression.
Evidence-Based Intervention
Black/African American people; Gay, bisexual, and other men who have sex with men (MSM); Youth ages 13 to 24; Young adults ages 25 to 34
Linkage to HIV medical care; Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Support service delivery model
Fort Lauderdale, FL
Macon, GA
Jackson, MS