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 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 who are not in care
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; 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
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
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
In weCare, a cyber health educator sent personalized messages through text, web-based apps, and Facebook to enrolled youth who identified as gay, bisexual, or other men who have sex with men (MSM), or transgender women, and who either had a new diagnosis of HIV or were not in care at the time of enrollment. Messages were personalized to each participant’s needs and were designed to support them as they navigated complicated health care systems as well as other challenges that affect care engagement (e.g., transportation, disclosure). The cyber health educator also moderated and posted information about health and well-being on an optional secret Facebook page that some participants chose to join. Participants were less likely to miss medical appointments and more likely to be virally suppressed after 12 months of the intervention.
Evidence-Informed Intervention
Youth ages 13 to 24; Young adults ages 25 to 34; Gay, bisexual, and other men who have sex with men (MSM); Transgender women
Retention in HIV medical care; Viral suppression
Use of technology and mobile health
Winston-Salem and Greensboro, NC
Nine sites implemented four evidence-based interventions, collectively known as Addressing STIs: Ask.Test.Treat.Repeat. The four intervention components are audio computer-assisted self-interview sexual history taking, patient self-collection of urogenital and extragenital site chlamydia/gonorrhea nucleic acid amplification test specimens, sexual and gender minority welcoming indicators, and provider training, with the overall goal to routinize STI screening, testing, and treatment in primary care. The interventions increased routine STI screening and testing of bacterial STIs based on reported behavioral risk.
Evidence-Informed Intervention
All clients
Beyond the care continuum
Clinical service delivery model
Washington, DC
FL
LA
STYLE 2.0 is a multi-component intervention designed to help reduce stigma and social isolation for Black gay, bisexual, and other men who have sex with men. The intervention relies on health care navigators who facilitate linkage and engagement activities. They also connect clients to behavioral health providers who conduct motivational interviewing, as well as to a mobile application that supports all intervention activities. STYLE 2.0 participation has been associated with positive trends across HIV care continuum outcomes, including retention in care and increased viral suppression.
Evidence-Informed Intervention
Gay, bisexual, and other men who have sex with men (MSM); Black gay and bisexual men
Retention in HIV medical care; Viral suppression
Clinical service delivery model; Outreach and reengagement activities
Durham, Orange, and Wake Counties, NC
Columbia, SC
LA Links is a combined data-to-care and client navigation approach that cross-references routinely collected HIV surveillance data with other secondary data sources to identify and locate people with HIV who are not in care, as well as those who are in care, but with high viral loads. Originally implemented in 2013 as part of the Care and Prevention in the United States Demonstration Project, LA Links improved linkage to care, reengagement in care, and viral suppression. Louisiana expanded the program statewide in 2016.
Evidence-Informed Intervention
People with HIV who are not in care; People with a new diagnosis of HIV
Linkage to HIV medical care; Viral suppression
Data utilization approach; Outreach and reengagement activities
Baton Rouge, New Orleans, and Shreveport, LA
MORE focuses on people who are not virally suppressed and/or who have not attended an HIV medical appointment in six months. Participants can choose from one of three MORE programs, depending on the intensity of services they want. Based on initial evaluation findings, participants who received more intensive MORE services were more likely to be virally suppressed and less likely to be lost to follow-up than those who received less intensive services.
Emerging Intervention
All clients
Retention in HIV medical care; Viral suppression
Clinical service delivery model; Support service delivery model
Washington, DC
