The Undetectables Viral Suppression Program (The Undetectables) is a client-centered model of integrated care that uses innovative, superhero-themed, anti-stigma social marketing, agency cultural change, and a toolkit of evidence-based antiretroviral therapy (ART) adherence strategies to support treatment adherence and viral suppression among people with HIV. The Undetectables was developed and launched in 2014 by Housing Works, a community-based organization in New York City, as a two-year demonstration project funded by the Robin Hood Foundation. The demonstration project evaluation showed a significant increase in the proportion of clients who were virally suppressed from 39% to 62%. Based on these promising results, the New York City Department of Health and Mental Hygiene (NYC Health Department) funded a citywide scale-up of The Undetectables in 2017 as part of the Ending the Epidemic (ETE) in New York State initiative, by subcontracting with seven agencies to implement the intervention in 20 different sites across NYC in areas with high HIV prevalence.
New York City, NY
While overall rates of viral suppression are higher in New York City than nationwide, at the end of 2019, approximately 23% of people with HIV in the city were not virally suppressed, and significant disparities persist by population.1 The Undetectables is intended to address barriers to medication adherence with the goals to improve ART adherence, retention in HIV medical care, linkage to social support services, and viral suppression.
Clients enrolled in The Undetectables receive integrated HIV primary care and case management services to help them maintain adherence to ART medication regimens. Through this intervention, providers have access to a toolkit of evidence-based adherence support strategies to use. Some strategies may be implemented across the entire agency to reach all clients, while others are chosen based on a client’s unique needs. These strategies include:
- Client-centered integrated case conferences and care planning
- Cognitive behavioral therapy groups and motivational interviewing
- Devices such as pill-boxes and timers
- Financial incentives for achieving viral suppression ($100 unrestricted gift cards for quarterly lab results showing a viral load <200 copies/ml.)
- Directly observed therapy (DOT)
Clinicians, case managers, and clients collaboratively develop a care plan that includes the adherence support strategies that will best serve the client. The toolkit includes a range of strategies to accommodate different client needs and agency capacities, with the core components—case conferencing (ideally with the client present), client-centered care planning, and financial incentives for viral suppression—being required for all clients.
A multilayered social marketing campaign promotes the importance of viral suppression both for the individual and to advance the community goal of ending the HIV epidemic by preventing new infections. The campaign is deployed to reach multiple audiences, including clients, direct service staff, support staff, and the public. The social marketing campaign features a novel component of a group of superheroes known as ‘The Undetectables,’ who demonstrate how being undetectable improves both individual and community health and well-being, making the individual a hero in combating the HIV epidemic. The campaign emphasizes the importance of maintaining an undetectable viral load to prevent HIV transmission to sexual partners, a message known as Undetectable = Untransmittable (U=U). Characters with HIV battle villains such as ‘Apathy,’ ‘Denial,’ ‘Fear,’ and ‘Stigma’ that threaten to undermine medication adherence and viral suppression. These characters are brought to life in a comic book series and a variety of print and digital materials that agencies are encouraged to post on their social media platforms, as well as in their brick-and-mortar locations.
Agency culture change starts with an organizational readiness assessment accompanied by ongoing technical assistance provided by Housing Works and the NYC Health Department. Support from senior agency staff is key for successful implementation, but information and training is provided for all staff on the importance of viral suppression as a key client and community health outcome, the evidence base supporting each component of The Undetectables intervention (including the financial incentives), and the importance of cross-agency participation to successful program implementation. The social marketing materials contribute to agency transformation by engaging staff and clients. Other activities like program launch events or Undetectables-themed health fairs promote the program and excite clients and staff alike.
“Featuring superheroes such as The Suppressor, The Harm Reducer, The Relentless Advocate, and The Gender Warrior, as well as foes who embody stigma, fear, apathy, and denial, the comics show that people with HIV have superpowers designed to empower, engage, and excite themselves and their community to enroll in The Undetectables.”
Since citywide implementation began in 2017, over 2,900 individuals have enrolled in The Undetectables at seven agencies. As of December 31, 2019, clients enrolled in the intervention had higher rates of viral suppression than people with HIV in the city as a whole.
|Evaluation data||Service utilization data and viral load laboratory values from the web-based system for reporting services funded by the NYC Health Department called eSHARE (Electronic System for HIV/AIDS Research and Evaluation)|
Source: Communication with NYC Health Department. 2022–2023.
Organizational readiness assessment. The Undetectables can be replicated by a variety of organizations that provide primary care and/or supportive services to people with HIV. Some may already offer comprehensive medical and case management services, while others will need to develop their capacity in specific areas or establish partnerships before they are ready to implement the intervention. Regardless, every agency must assess which resources they already have in place, which are still needed, and the steps they must take to fill the gap. To prepare for replicating The Undetectables, agencies must evaluate their readiness to dedicate staff and resources to HIV primary care and viral load monitoring, adopt an organizational culture centered on viral suppression, plan an Undetectables social marketing campaign, provide HIV case management services with a focus on medication adherence support, and deliver financial incentives that reward viral suppression. The organizational readiness assessment is intended to help organizations determine where they currently have the capacity to implement The Undetectables and which areas require further development, to enable program leadership to think critically about current resources and develop a plan to fill any gaps.
Training. Multiple training opportunities ensure that staff are fluent in the goals of The Undetectables and the underlying concepts of viral suppression, medication adherence, harm reduction, and ending the epidemic. While some topics, such as motivational interviewing, may be familiar to some staff, the inclusion of these topics shifts the perspective and provides an occasion for refresher trainings. In addition, staff who do not directly serve clients are encouraged to complete trainings on the main points of The Undetectables and ending the epidemic in order to share agency-wide ownership of this vital goal.
Organizational Infrastructure. Implementation of The Undetectables requires specific organizational infrastructure for executing the intervention and evaluating outcomes. This capacity can be filled by the lead agency or through formal partnerships with other organizations. General capabilities include:
- HIV primary care: Organizations need to ensure access to primary medical care, with an expertise in providing care for people with HIV. Providers should have expertise working with clients to achieve viral suppression and promote ART adherence.
- Case management: The Undetectables requires expert case management for people with HIV. Case managers may work in a variety of settings, including Health Homes, supportive housing, and day programs. They must regularly engage with clients, connect them to necessary social services, and understand the importance of viral suppression to an individual’s overall well-being. Organizations must be able to deliver a strong training program for case managers to ensure that clients receive the full benefit of case management.
- Fiscal management: Agencies need financial management systems and processes in place to manage reimbursement for services and incentive distribution to clients. Organizations can build their budgets under a variety of funding scenarios, including public and private grants, and can benefit from understanding how this intervention may tie into their state’s Medicaid program.
- Behavioral health and substance use treatment: Clients who struggle to adhere to ART medication regimens often face significant behavioral health challenges, including mental illness and substance use. Organizations must be able to connect clients to behavioral health services. A harm reduction approach that meets clients where they are at is essential when addressing these issues.
- Monitoring and evaluation: Success of The Undetectables relies on an organization’s ability to track client viral load and engagement in care and services over time. Data management tools enable care providers to evaluate client progress and identify which tools of the intervention are required to help the client reach viral suppression. Typical data systems include electronic medical record (EMR) systems, electronic case management systems, systems for managing referrals to outside services and organizations, and Microsoft Excel or similar software to create and analyze data sets.
- Program administration: An organization’s support for The Undetectables is reflected in the administrative systems it puts into place to facilitate the program. This includes necessary policies and procedures; intake, enrollment, consent, and other forms; standing meetings to evaluate program performance and conduct training; internalized quality management processes; and opportunities to communicate and reinforce organizational commitment to ending the HIV epidemic.
Core Staff. In addition to regular agency staff providing medical, case management, and other essential services, core staff specific to implementing The Undetectables at each agency include:
- Program Coordinator (1.0 FTE). Responsible for coordinating all components including training of staff, social marketing development and distribution, ensuring service delivery, program enrollment, timely assessments, documentation, and reporting.
- Data Specialist (Up to 1.0 FTE). Responsible for collecting and entering Undetectables data into eSHARE or other systems as needed, ensuring accuracy and completeness of data, establishing protocols, providing internal status reports, managing data, and assuring quality.
- Undetectables Case Manager (Optional) (Up to 1.0 FTE). Provides additional support for implementation including enrollment, assessments, toolkit service delivery, case conferencing, and care planning. Originally, existing agency case managers were tapped to provide this support; however, during implementation some agencies’ case managers already had high caseloads and could not take on the additional activities. Therefore, additional funding was allocated for up to 1.0 case manager FTE to support The Undetectables.
Technical Assistance. A significant partnership for the scale-up of The Undetectables is between Housing Works and the NYC Health Department. Housing Works has provided the majority of technical assistance and all social marketing materials to subcontracted agencies (initially and on an ongoing basis).
“The success of The Undetectables relies on a community of staff and clients who take ownership of ending the AIDS epidemic.”
- All subcontracted agencies have fully integrated The Undetectables into their organizational and clinical workflows. Significant time and effort were needed to obtain buy-in from staff, especially HIV case management staff. The most successful agencies framed The Undetectables as a program that could facilitate the work HIV case management staff and HIV primary care staff were already doing. NYC Health Department is currently expanding The Undetectables program to other agencies, while continuing to provide the financial incentives support to the initial agencies.
- The NYC Health Department has been fortunate to receive steady funding from the ETE in New York State Initiative on an annual basis and has benefitted from the flexibility in the funding from New York City. This funding allows for ongoing support and technical assistance provided by Housing Works.
- The subcontracted agencies participate in quarterly roundtables where agencies discuss their implementation strategies as well as challenges. They share lessons learned and help strategize solutions to problems.
- Rigorous data reporting and analysis are essential to tracking client progress and monitoring program evaluation. The intervention offers multiple opportunities to establish cross-cutting quality assurance teams and meetings to ensure the best possible outcomes for all clients.
- Buy-in from agency leadership, HIV case management staff, and HIV primary care staff is imperative. Obtaining and maintaining buy-in requires relationship-building among staff and developing a shared understanding of the program and how it can strengthen existing service delivery.
- Integrating the program into existing HIV case management programs has many benefits (e.g., leveraging the expertise of case management to implement tools in the toolkit), but the potential impact of The Undetectables is therefore dependent on the capacity of existing HIV care management program(s) to serve clients.
- Some of the sites have a waiting list for The Undetectables program because HIV care management programs are operating at full capacity. In the second year of the NYC ETE-funded scale-up, the NYC Health Department allowed programs to cover up to 1.0 FTE case manager on their budget, independent of an HIV care management program already existing at their agency. This has allowed programs to enroll more clients, including individuals who do not meet the specific eligibility requirements of an established HIV care management program.
- Because The Undetectables is integrated into existing HIV care management programs, some staff have found the intake assessment and reassessment to be repetitive. The NYC Health Department revised the assessment forms to narrow them down to the essential components of the program, but some repetition of questions does still exist due to reporting requirements by the NYC Health Department and other entities funding HIV care management programs. To streamline workflows, subcontracted agencies are allowed to supplement their HIV care management assessment forms with questions required for The Undetectables assessment that do not already appear on their forms.
- The Undetectables Viral Suppression Program
- Introduction to the Undetectables and Ending AIDS Training Guide (available upon request - see contact below)
- The Undetectables Organizational Readiness Checklist (available upon request - see contact below)