The University of Mississippi Medical Center implemented a Postpartum Retention and Engagement Quality Improvement Initiative in 2017 to improve linkage to care, retention in care, and viral suppression among postpartum women with HIV. This intervention uses a combination of care coordination, printed materials, case management services, and improved collaboration and coordination between the Adult Special Care Clinic, which provides comprehensive HIV medical care, and a Perinatal HIV Program. The comprehensive intervention significantly improved retention in HIV care and increased viral suppression at both six and 12 months postpartum.
Evidence-Informed Intervention
Women; Pregnant and postpartum people
Retention in HIV medical care; Viral suppression
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
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
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
Bienestar developed TransActivate to improve timely engagement and retention in HIV care among Latina transgender women. Linkage coordinators/peer navigators use a strengths-based approach to help clients reach their goals of entering and staying in medical care to ultimately reach viral suppression.
Transgender women; Hispanic/Latina(o/x) people
HIV diagnosis; Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Support service delivery model
Ten organizations across the U.S. integrated Community Health Workers (CHWs) into their multidisciplinary care teams. Enrolled clients had statistically significant improvements in viral suppression, antiretroviral therapy prescription, and appointment attendance after six months in the program.
Evidence-Informed Intervention
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Support service delivery model
Birmingham, AL
Mobile, AL
Fort Myers, FL
Lake Charles, LA
New Orleans, LA
Baltimore, MD
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
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