These resources include implementation tools developed under the Ryan White HIV/AIDS Program (RWHAP). Tools were developed under the RWHAP Special Projects of National Significance (SPNS) research and demonstration program as well as various HRSA technical assistance and training projects.
- CrescentCare Start Initiative
An initiative designed to link people newly diagnosed with HIV to care and treatment within 72 hours. (CIE) - Engaging Hard-to-Reach Populations
Tools (training manual, curriculum, webinars) for programs on how to create programs to reach clients not in HIV care via outreach, motivational interviewing, patient navigation, case management, and other models. (IHIP) - Improving Health Outcomes: Moving Patients Along the HIV Care Continuum and Beyond
Resources to help HIV care programs improve health outcomes along with HIV care continuum. Materials include a manual, case studies, pocket guides, and TA webinars and cover a broad range of approaches and audiences. (IHIP) - Improving STI Screening and Treatment among People with or at Risk for HIV
Project developed a Sexual History Taking Toolkit with resources on screening, sexual history assessment. (SPNS ETAC) - In It Together Health Literacy Project
Tools to help health professionals incorporate health literacy approaches into their services in order to improve client engagement and retention in HIV care. (In It Together) - Linkage to Care Specialist (LTC-S) Project
A client-centered, resiliency-based model to link newly diagnosed individuals to HIV care. (CIE) - Long-Acting Injectables for HIV Antiretroviral Therapy
What jurisdictions can do to enhance implementation of the relatively new HIV treatment option: long-acting injectable antiretroviral therapy. (TAP-in) - MORE: Mobile Outreach Retention and Engagement
A tailored service delivery model, which includes increasing access to supportive services and providing HIV care services in community settings. (CIE) - PositiveLinks
A clinic-based mobile app to promote linkage to and engagement in HIV care by connecting clients to a virtual local community. (CIE) - Rapid ART: An Essential Strategy for Ending the HIV Epidemic
What HIV care providers need to do to strengthen or develop a rapid ART program that will provide antiretroviral therapy to patients quickly—ideally on the same day they receive their HIV diagnosis. (TAP-in) - RUSH (Routine Universal Screening for HIV)
HIV screening of all 16 and older emergency department patients who have an IV line inserted and blood drawn. (CIE) - Social Networks Testing
Social Networks Testing demonstrates that members of high-risk groups are often more effective at identifying and recruiting HIV-positive and at-risk individuals than traditional testing and outreach models. Overview, replication tips, and case study. (IHIP) - SPNS Social Media Initiative Demonstration Site Resources
Monographs and implementation manuals for ten effective projects focusing on engagement and retention of youth in HIV care. (SPNS ETAC) - Trauma-Informed Approaches Toolkit
Review of the basics of trauma and modules on trauma-informed approaches in the delivery of HIV care. - Using Community Health Workers to Improve Linkage and Retention in Care
Resources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model. Includes extensive implementation guide and TA webinars. (SPNS ETAC)
- E2i: Black MSM
These evidence-informed interventions are to improve engagement and retention of Black MSM in HIV care. Each intervention includes an Implementation Guide, overview video and videos from each implementation site, recruitment materials and a learning module for staff. (E2i)- Tailored Motivational Interviewing
- TXTXT (Text Messaging Intervention to Improve Antiretroviral Adherence among HIV-Positive Youth)
- Project CONNECT (Client-oriented New Patient Navigation to Encourage Connection to Treatment)
- Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex With Men
Monographs are for engaging Black men who have sex with men (MSM) in HIV medical care, behavioral health care, and support services and improving their health outcomes. (SPNS Black MSM Initiative)- Project Vogue: GMHC (NYC)
- +Love: Crescent Care (New Orleans)
- STYLE 2.0: Duke University (Durham)
- Care Engagement Project: Christian Community Health Center (Chicago)
- The Village Project: Parkland Health & Hospital System (Dallas)
- Building Brothers Up: Friends Research Institute, Inc. (Los Angeles)
- ERASE: East Bay Advanced Care (Oakland)
- WITH U: Washington University, Project ARK (St. Louis)
- HisHealth: Models of Care for Young, Black, Men who Have Sex with Men
Project features 11 models of care (summary fact sheets and program tools) and multidisciplinary training modules for both providers and community agency leaders and staff. (CEBACC) - Well Versed
Resource for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)
- Assess, Test, Link- Achieve Success (ATLAS) Program
Integrates jail-based case managers into the community HIV case management system to engage and subsequently link incarcerated individuals as they transition from jail to community. Overview, replication tips, and case study. (IHIP) - Care Coordination Intervention
Intervention promotes HIV medication access, coverage, and pickup for individuals transitioning from correctional facilities. Overview, replication tips, and case study. (IHIP) - Correctional Health Linkage Interventions
Implementation resources for an evidence-based intervention to facilitate linkage to community-based HIV care after incarceration. Includes manual, training curriculum, and tools. (IHIP) - Enhancing Linkages to Care for Women Leaving Jail
Innovative, evidence-informed intervention integrates jail-based case managers to work with jail-based discharge planners and peers to support HIV-positive women as they transition from jail to the community. Overview, replication tips, and case study. (IHIP) - Maricopa County: Expanding Jail Services & Improving Health for Incarcerated People with HIV
Implementation Guide and FAQs (IHIP) - Navigator Case Management
Case management to promote healthy behaviors among people with HIV post-incarceration. (CIE) - Project START
Using a client-focused, personalized, Incremental Risk Reduction approach, the Project START intervention improves linkage and retention in care among people with HIV who are leaving correctional facilities to return to the community. (CIE) - Transitional Care Coordination
Evidence-based intervention to facilitate linkage to community-based HIV care after incarceration featuring a training curriculum for agencies and implementation activities and tools. (DEII) - Video Conferencing Intervention: Case Study, Overview, and Replication Tips
This intervention allows community-based case managers to connect via video chat with incarcerated clients prior to release. Overview, replication tips, and case study. (IHIP)
- AFC: Safe & Sound Return Partnership
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - AFH: Project CORE
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - Bexar County: CASE Management Initiative
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations
Implementation manuals and other tools on models of care (e.g., medical homes, patient navigation, case management) for people living with HIV who have co-occurring conditions (substance abuse, mental health, homelessness). (SPNS ETAC) - City of Pasadena: Operation Link
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - City of Paterson: Coordination of Housing & Employment Services
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - FHCSD: Coordinated Services Intervention
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - Fenway Health: Housing & Employment Project
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - GMHC: Project Health
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - HHOME Homeless Health Outreach Mobile Engagement
Implementation Guide and FAQs (IHIP) - KC Life 360: Employment-Focused Intervention to Link Clients to Support Services and Housing
Implementation Guide and FAQs (IHIP) - Kansas City, MO: KC Life 360
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - Leveraging Housing Opportunities to Promote Retention in Care for People with HIV
Rental assistance, housing placement assistance, or supportive permanent housing for low-income persons with HIV. (CIE) - PIHC: H.O.M.E.S.
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - PRC: Integrative Health Analysis
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC) - Yale, LCS: Project HERO
Implementation manual, tip sheets and other resources from the SPNS Housing and Employment Project. (SPNS ETAC)
- Curing Hepatitis C among People of Color Living with HIV
Expansion of HCV service capacity including coordination of HIV and HCV care and enhanced surveillance. (SPNS) - Integrating Hep C Treatment into HIV Care
Methods for integrating HCV and HIV care, outlined in an implementation guide, two case studies, and pocket guide that present steps, best practices, and tools (e.g., staffing, checklists). (IHIP) - Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care
Training curriculum and manual on how to set up a buprenorphine program within an HIV agency with tools and examples of programs (spotlights and handouts). (DEII) - Integration of Buprenorphine into HIV Primary Care Settings: Tools from the Integrating HIV Innovative Practices Program
Training manual and curriculum on setting up buprenorphine services, covering prescribing, selecting and managing patients, patient education, staff training. Includes educational webinars and FAQs. (IHIP)
- Bilingual/Bicultural Care Team Intervention
Culturally and linguistically appropriate treatment and services to retain Hispanic/Latinx people in HIV care. (CIE) - Building Effective Interventions for Latino Clients
Webinar featuring two demonstration sites implementing effective linkage and retention strategies for Latino clients with HIV and substance use disorders. (SPNS) - Culturally Appropriate Engagement and Service Delivery with Latino/as
Webinar series on ways to improve HIV primary care patient outcomes for Latinos/as who are incarcerated or have a history of incarceration. (SPNS) - Culturally Appropriate Interventions of Outreach, Access and Retention among Latino/a Populations Initiative: An Intervention Monograph
Detailed descriptions of nine Latino SPNS demonstration projects. (SPNS) - Viviendo Valiente: Multi-Level Intervention Linking Latinos to HIV Care
Implementation Guide (IHIP)
- Creating Innovative Oral Health Care Programs
Training manual (with lessons learned), a curriculum (with instructions and oral health replication models), a pocket guide for providers, and webinars on dental case management and clinical aspect of oral care. (IHIP) - Integration of Oral Health and Primary Care Technical Assistance Toolkit
Outlines steps to oral care integration and provides practical, evidence-based advice on how to implement and sustain them in your program. (HRSA HAB)
- Building Blocks to Peer Success: Training HIV-Positive Peers to Engage PLWHIV in Care
Multi-part manual to train HIV-positive peers as clinic staff to engage people living with HIV in care. Companion toolkit on establishing a clinic peer program (Peer Center, HRSA HAB) - Peer Linkage and Re-engagement of Women of Color with HIV
Resources to prepare women of color living with HIV to provide peer support to link/re-engage clients in HIV primary care. Includes training curriculum for peers and a manual for staff on how to implement a peer program, with extensive tips and tools in both. (DEII) - Using Community Health Workers to Improve Linkage and Retention in Care
Resources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model. Includes extensive implementation guide and TA webinars. (SPNS ETAC)
- Improving STI Testing and Treatment among People with or at Risk for HIV
Toolkit includes implementation resources for four evidence-based interventions. (SPNS ETAC)- Audio Computer-Assisted Self-Interview (ACASI) Sexual History
- Patient Self-Collected Nucleic Acid Amplification Test (NAAT) Specimens
- Lesbian, Gay, Bisexual, Transgender, Queer, and other sexual and gender minority individuals (LGBTQ+) Welcoming Clinical Space Indicators
- Provider Training
- Enhancing Linkage of STI and HIV Surveillance Data in the RWHAP
Toolkit provides guidance for designing, implementing, and evaluating a data linkage and integration project. (SPNS ETAC)
- Integrated HIV and Opioid Addiction Treatment with Buprenorphine
- On-site buprenorphine treatment guided by an experienced HIV physician trained in MI techniques. (CIE)
- Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care
Training curriculum and manual on how to set up a buprenorphine program within an HIV agency with tools and examples of programs (spotlights and handouts). (DEII) - Integration of Buprenorphine into HIV Primary Care Settings: Tools from the Integrating HIV Innovative Practices Program
Training manual and curriculum on setting up buprenorphine services, covering prescribing, selecting and managing patients, patient education, staff training. Includes educational webinars and FAQs. (IHIP) - Kaleidoscope of Care: Responding to the Challenges of HIV and Substance Use
Cross-disciplinary training curriculum on the relationship between HIV infection and substance use. Modules include health promotion/adherence, harm reduction, interdisciplinary care, and care engagement strategies. In English and Spanish. (SPNS ETAC) - Strengthening Systems of Care for People with HIV & Opioid Use Disorder
Extensive collection of tools and guides for improved coordination among HIV and behavioral health/substance use service providers. (SPNS ETAC)
- Active Referral Intervention
This intervention uses Disease Intervention Specialists (DIS) to more actively and immediately link clients to HIV care services. Overview, replication tips, and case study. (IHIP) - Clinic-Based Surveillance-Informed
Combines clinic and health department surveillance data to identify and re-engage people with HIV who are out of care. (CIE) - Emergency Department and Hospital-Based Data Exchange (ED Alert)
A real-time data to care program to identify and re-engage people with HIV in care. (CIE) - Link-Up Rx
Data to care (D2C) program that aims to increase retention in care and viral suppression among people with HIV by using prescription refill information to decrease the length of time between refills and reduce antiretroviral therapy interruption. (CIE) - Louisiana Public Health Information Exchange
This intervention facilitates bidirectional information exchange between hospital system records and public health surveillance data to identify and link out-of-care HIV-positive clients back to care and treatment. Overview, replication tips, and case study. (IHIP) - My Health Profile Continuity of Care Record Intervention
My Health Profile is a patient portal leveraged across a regional health network containing critical health information to improve continuity of care. Overview, replication tips, and case study. (IHIP) - SPNS Systems Linkages Project
Manuals and tools from five demonstration sites on how to replicate linkages across public health systems via innovative strategies (e.g., referral systems, care engagement techniques, patient navigation, electronic medical records). (SPNS ETAC) - SPNS HIV/STI Data Integration Project
Toolkit with guidance on designing, implementing, and evaluating a data integration project. (SPNS ETAC) - Strengthening Systems of Care for People with HIV & Opioid Use Disorder
Extensive collection of tools and guides for improved coordination among HIV and behavioral health/substance use service providers. (SPNS ETAC)
- PositiveLinks
A clinic-based mobile app to promote linkage to and engagement in HIV care by connecting clients to a virtual local community. (CIE) - SPNS Social Media Initiative Demonstration Site Resources
Monographs and implementation manuals for ten effective projects focusing on engagement and retention of youth in HIV care. (SPNS ETAC) - TAVIE Red: Mobile Application for Self-Management
Mobile application that utilizes gamification to increase health and psychological self-management and assists case managers with connecting with clients. (CIE) - Virology FastTrack
A clinical decision support system that generates alerts in EMRs and improves appointment follow up. (CIE)
- Peer Linkage and Re-engagement of Women of Color with HIV
Tools developed under an implementation science approach. (DEII) - SPNS Transgender Women of Color Initiative Intervention Manuals
Intervention ideas for engaging transgender women of color living with HIV into HIV care, with intervention descriptions and lessons learned from each of nine sites. (SPNS ETAC)
(IHIP) - Text Me, Girl!: Transgender-Specific Text Messaging to Support Care Engagement
90-day theory-based, transgender-specific, automated text-messaging intervention (IHIP)
- Enhanced Patient Navigation for Women of Color with HIV
Tools for use of patient navigators to support women of color living with HIV to optimize their engagement in care via support and patient empowerment. Includes training curriculum for navigators and manual for program staff on implementing a program. (DEII) - Enhancing Access for Women of Color Initiative
(IHIP) - Peer Linkage and Re-engagement of Women of Color with HIV
Resources to prepare women of color living with HIV to provide peer support to link/re-engage clients in HIV primary care. Includes training curriculum for peers and a manual for staff on how to implement a peer program, with extensive tips and tools in both. (DEII) - Women of Color: Enhancing Access
Guide for ways to expand/improve services for women of color living with HIV, with planning and implementation steps based on best practices from demonstration sites, from steps on getting started to lessons learned. (IHIP)
- Expanding Care for People Living with HIV Toolkit
Actions that health agencies can take to either add or increase HIV care to their service offerings. Four steps are outlined, and each presents an implementation tool to guide that step. Also presents lessons learned. (SPNS ETAC) - Optimizing the Care Team
Insights on operating Care Teams: multidisciplinary collection of providers who work together to meet multiple patient needs to improve care delivery and outcomes. Best practices cover: preparation, staffing, buy-in, formalization, and adaptability. (SPNS ETAC) - Patient Engagement and Care Coordination in HIV Health (PEACCH) Tool
Steps for setting up an HIV care coordination p
- Building Futures: Supporting Youth Living with HIV
Activities agencies can undertake to enhance delivery of HIV care to youth living with HIV, presented under the themes: clinical service models, infrastructure development, information program development, and wraparound services. (HRSA HAB) - HisHealth: Models of Care for Young, Black, Men who Have Sex with Men
Collection features 11 models of care (summary fact sheets and program tools) and online multidisciplinary training modules for providers, community agency staff, and leaders. (CEBACC) - Project ACCEPT
A group-based intervention for cisgender youth, 16- to 24-years old, to improve engagement in HIV care. (CIE) - Project STYLE
An innovative model that links youth to the care step of the HIV care continuum. (CIE) - SPNS Social Media Initiative Demonstration Site Monographs
Intervention monographs from ten demonstration sites on technology-based projects to improve engagement, retention, and outcomes in youth. - Tailored Motivational Interviewing
Motivational Interviewing reimagined for youth with new HIV diagnoses to ultimately improve retention in HIV care. (CIE) - Well Versed
Resources for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)
Guide to Sources
- ACE TA Center. Tools to build the capacity of the RWHAP community to navigate the health care landscape help consumers access and use their health coverage. 2019-2022.
- AETC NCRC: AETC National Coordinating Resource Center. Ongoing.
- Black MSM Initiative. Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex With Men. 2018-2022.
- CEBACC: Center for Engaging Black MSM Across the Care Continuum. Ended 2018.
- CIE: Center for Innovation and Engagement. 2018-2021.
- CQII: Center for Quality Improvement and Innovation. 2020-2024.
- DEII: Dissemination of Evidence-Informed Interventions. SPNS project evaluating implementation packages for four interventions. TA project: 2015 - 2020.
- HRSA HAB: Health Resources and Services Administration HIV/AIDS Bureau.
- IHIP: Integrating HIV Innovative Practices - developed and disseminated replication tools derived from the SPNS program after projects were completed.
- In it Together Health Literacy Project: Two projects to help health professionals incorporate health literacy approaches into their services. 2014-2019.
- SPNS: Special Projects of National Significance: Program under RWHAP Part F responsible for HIV care model identification, evaluation, and dissemination.
- SPNS ETAC: Each SPNS project has an Evaluation and TA Center (ETAC) with responsibility for compiling dissemination tools (manuals, training resources) developed under the initiative.
Innovation Pipeline
Evidence-Informed Interventions
- Best Practices Compilation Database features approaches that have been shown to improve HIV outcomes in real world settings
Watch for resources from these ongoing RWHAP projects.
Comprehensive inventory of SPNS-derived resources on the TargetHIV website.
Ryan White Conferences
Searchable database of hundreds of Conference Presentations from select National Ryan White Conferences.