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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Rapid ART Program Initiative for New Diagnoses (RAPID) was designed to connect people with a new HIV diagnosis to ART within five days of diagnosis and within one day of their initial care visit. Linkage navigators counseled people on HIV care, identified an available clinician capable of immediately prescribing ART, scheduled the clinical appointment, and connected people to additional support services. RAPID led to a reduction in median time between initial diagnosis and both ART initiation and viral suppression.
Evidence-Based Intervention
People with a new diagnosis of HIV
Linkage to HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Clinical service delivery model
San Francisco, CA
The goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
Evidence-Informed Intervention
People with HIV who are not in care
Linkage to HIV medical care; Viral suppression
Clinical service delivery model; Data utilization approach
Seattle, WA
JumpstART launched in 2016 as part of New York State’s Ending the Epidemic initiative, changing the service delivery model of eight sexual health clinics to include an initial prescription of ART after an HIV diagnosis and prior to linkage to the community provider. Between November 2016 and September 2018, 60% of JumpstART clients received ART on the same day as diagnosis. JumpstART clients were also more likely to reach viral suppression within three months compared to non-JumpstART clients.
Evidence-Informed Intervention
People with a new diagnosis of HIV
HIV diagnosis; Linkage to HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Clinical service delivery model
New York City, NY
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
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
Wellness Web 2.0 is a text message-based intervention that offers health education tools, appointment reminders, and navigation services to increase linkage to and retention in care for youth and young adults with HIV. Clients across 27 counties in South Texas enrolled in the Wellness Web 2.0 program had improvements in linkage to HIV medical care and viral suppression.
Emerging Intervention
Youth ages 13 to 24; Young adults ages 25 to 34
Linkage to HIV medical care; Viral suppression
Use of technology and mobile health
Corpus Christi, TX
San Antonio, TX
Laredo, TX
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
Expanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
Evidence-Informed Intervention
People who are unstably housed
Viral suppression; Beyond the care continuum
Support service delivery model
Kansas City, MO
To better integrate primary care with behavioral health services, providers were trained on trauma-informed care and contracts and standards of care were modified to require that medical providers conduct mental health screenings. As a result, receipt of mental health services and care retention rates improved.
Emerging Intervention
People with a history of trauma
Retention in HIV medical care; Viral suppression; Beyond the care continuum
Clinical service delivery model
Fort Lauderdale, FL