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.
Search Results
Displaying 1 - 10 of 10
CoRECT was a data to care project to identify and reengage people with HIV who were newly out of care. It included a clinic and health department data reconciliation process to identify missed laboratory results or appointments and create the out-of-care list, case discussions via telephone to review the combined list, and field epidemiologist outreach to assist clients with making appointments, securing transportation, and arranging referrals. The intervention employed strengths-based case management techniques and motivational interviewing to contact identified people within 30 days, reengage them in care, and reduce time to viral suppression.
Evidence-Based Intervention
People with HIV who are not in care
Linkage to HIV medical care; Retention in HIV medical care
Outreach and reengagement activities; Data utilization approach
MA
CT
Philadelphia, PA
Enlaces Por La Salud is an HIV linkage, navigation, and education program for Mexican men and transgender women. The intervention is grounded in a transnational framework for providing cultural context to support the delivery of one-on-one educational sessions to Latina(o/x) people with a new HIV diagnosis, as well as people with HIV who are not yet retained in care. After 12 months, the majority of people participating in Enlaces Por La Salud were retained in care and reached viral suppression.
Emerging Intervention
Hispanic/Latina(o/x) people; Gay, bisexual, and other men who have sex with men (MSM); Transgender women; People with a new diagnosis of HIV; People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Support service delivery model; Outreach and reengagement activities
Wake County, NC
Mecklenburg County, NC
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
New York, NY
The Bottom-Up Project is a multi-organizational initiative focused on leveraging health information exchange data and peer navigation. Using real-time clinical data, in combination with linkage to HIV care and social services, the Bottom-Up Project locates and reengages people with HIV who are not currently in medical care and are not virally suppressed. Through this collaboration, over half of patients on the lost-to-follow-up list were found and invited to enroll in the linkage to care/reengagement program.
Emerging Intervention
People with HIV who are not in care
Retention in HIV medical care
Data utilization approach; Outreach and reengagement activities
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; Black/African American people; Gay, bisexual, and other men who have sex with men (MSM); People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Support service delivery model
Los Angeles, CA
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; People with HIV who are not in care; People with a new diagnosis of HIV
Retention in HIV medical care
Outreach and reengagement activities
Oakland, CA
Link-Up Rx is a pharmacy-data-based Data to Care program implemented by the Detroit Health Department in partnership with the Michigan Department of Health and Human Services and a specialty pharmacy. Using pharmacy data to identify clients in need of follow-up greatly reduced the amount of time for clients to appear on “not in care” lists compared to traditional D2C approaches. Protocols for a three-tiered outreach and reengagement approach were developed to connect clients back to antiretroviral therapy and HIV care following a missed pharmacy pick-up. Nearly half of identified clients were linked back to their pharmacy or other HIV medical services.
Emerging Intervention
People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Data utilization approach; Outreach and reengagement activities
Detroit, MI
This data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.
Evidence-Based Intervention
People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Outreach and reengagement activities; Data utilization approach
San Francisco, CA
Project CONNECT uses linkage coordinators to effectively engage people in HIV medical care. It focuses on people with newly diagnosed HIV or people with HIV who are transferring their care or have been out of care. AIDS Taskforce of Greater Cleveland implemented Project CONNECT as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Project CONNECT was successful in increasing the number of clients retained in HIV care and who reached viral suppression.
Evidence-Informed Intervention
People with a new diagnosis of HIV; Black gay and bisexual men; People with HIV who are not in care
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Support service delivery model
Cleveland, OH
This medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.
Emerging Intervention
People with HIV who are not in care; People with multiple chronic conditions
Linkage to HIV medical care; Retention in HIV medical care
Clinical service delivery model
New York, NY