Evidence-Informed Interventions in Four HIV Care Continuum Manuals


Evidence-informed interventions for linking, re-engaging, and retaining persons with HIV (PWH) in HIV care. Interventions were tested by HRSA's Special Projects of National Significance (SPNS) program. The manuals are for Ryan White-funded (and other) HIV agencies and focus on HIV care for specific populations through approaches like cross-agency coordination and use of peers in care teams.

Transitional Care Coordination


  • What Is It? An intervention for strengthening connections between community health and jail health care systems
  • Why Is It Needed? Without transition assistance, people with HIV who are released from jail are at risk of unstable housing; lack of access to health insurance and medication; overdose due to period of detoxification; exacerbation of mental health conditions; and lack of social supports when exposed to the same high-risk communities from which they were incarcerated.
  • Who Can Deliver It? Organizations, agencies, clinics, health departments, and jails.

Download the Transitional Care Coordination Manual 

Integrated Buprenorphine Treatment


  • What Is It? An HIV primary care intervention that aligns with the medical home model and follows principles of harm reduction.
  • Why is It Needed? Dramatic increases in opioid- related fatal overdoses and acute hepatitis C infections in recent years underscore the urgent need to identify and treat opioid use disorder in people with HIV. Buprenorphine treatment delivered in HIV clinics is associated with decreased opioid use, increased ART use, higher quality of HIV care and higher quality of life.
  • Who Can Deliver It? HIV primary care providers.

Download the Buprenorphine Manual 

Patient Navigation for WOC


  • What Is It? A structured patient navigation model to increase retention and ultimately improve health outcomes among Women of Color.
  • Why Is It Needed? Patient navigators are critical members of the healthcare team focused on reducing barriers to care for the patient at the individual, agency, and systems levels.
  • Who Can Deliver It? Organizations, agencies, and clinics.

Download the Patient Navigation Manual

Peer Linkage for WOC


  • What Is It? A short-term, peer-focused model to increase linkages and retention to care among Women of Color.
  • Why Is It Needed? Peers can help remove patient barriers and improve access to HIV primary care and support services because they have often experienced the same barriers and they can motivate attitudinal and behavioral changes in people with HIV.
  • Who Can Deliver It? Organizations, agencies, and clinics.

Download the Peer Linkage Manual