Achieving Viral Suppression

When HIV is suppressed, or controlled by medications and other care, people are protected from HIV-related illnesses, and are much less likely to pass the virus to their sexual partners or unborn children. Another word for "viral suppression" is "undetectable" meaning the levels of HIV in a person's blood (viral load) are so low that the laboratory test cannot measure them. 

Best Practices

  • Best Practices Compilation
    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.
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    Howard Brown Health established a specialized drop-in clinic and support groups, and implemented organizational initiatives to provide culturally relevant and gender-affirming services for transgender and non-binary people, including transgender women of color. The goal of this intervention was to optimize engagement in HIV services and primary care. From 2012-2021, the number of transgender and non-binary people served in primary care at Howard Brown Health more than tripled. In addition, after 24 months, participants were more likely to have been prescribed ART and to be virally suppressed than at baseline.
  • Best Practices Compilation
    Hispanic and Latino clients served by the team received culturally responsive care and linkages to external community resources, with resulting greater retention in care and improved viral suppression rates.
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    2BU is a case management intervention designed to engage and reengage Black men who have sex with men with HIV into HIV care services. Peer case managers work closely with clients to increase HIV health literacy, troubleshoot accessibility issues to HIV care, and connect clients directly to behavioral health and support services. Clients who participated in 2BU had increased retention in care and viral suppression 12 months after enrollment.
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    Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care is an integrated care approach designed to reduce opioid use and overdose while improving client engagement in HIV care. Greater Lawrence Family Health Center and Med Centro, Inc. implemented this integrated care approach as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Clients who participated in this intervention received integrated care—treatment for opioid use disorder (OUD) and HIV in a single setting—to improve retention in care, viral suppression, and engagement in OUD treatment.
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    Clínica Bienestar (Spanish for “Wellness Clinic”) was developed to provide comprehensive, integrated HIV primary care services to Spanish-speaking and bilingual people of Puerto Rican ancestry, with HIV who inject drugs. Clínica Bienestar is a multilevel, multipronged intervention combining evidence-based practices in behavioral health and HIV medical care with a transnational approach to care. Clínica Bienestar positively impacted retention in HIV medical care and viral suppression.
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    Collaborative Care Management (CoCM) integrates mental health and primary care, with a care team of a primary care provider, behavioral health care manager, and psychiatric consultant. Together they provide comprehensive and coordinated care to people with HIV who have co-occurring depression or other psychiatric disorders. Four sites implemented CoCM as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. CoCM led to statistically significant increases in antiretroviral therapy (ART) prescription and viral suppression.
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    Ten organizations across the U.S. integrated Community Health Workers (CHWs) into their multidisciplinary care teams. Enrolled clients had statistically significant improvements in viral suppression, antiretroviral therapy prescription, and appointment attendance after six months in the program.
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    E-VOLUTION is a two-way text messaging intervention, originally developed by Washington University School of Medicine and piloted at Project ARK. The intervention focuses on improving health outcomes for youth, particularly young Black men who have sex with men. E-VOLUTION was designed for people ages 18-29 who have HIV and are receiving clinical care but require support to remain adherent. E-VOLUTION was evaluated and found to improve viral suppression and retention in care rates.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    This intervention to rapidly re-house people with HIV was implemented at multiple New York City shelters and was associated with significant improvements in viral suppression.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    Healthy Divas focuses on empowering transgender women with HIV to achieve their personal health goals. Three sites implemented the intervention as part of the E2i initiative funded through the RWHAP Part F SPNS program from 2017 through 2021. Both engagement in HIV care and having an antiretroviral therapy prescription improved significantly for clients 12 months after enrollment in Healthy Divas.
  • Best Practices Compilation
    The HIV Clinical Pharmacist Services intervention shortens the time between referral to and engagement in care by allowing newly referred clients to see pharmacists in addition to other clinical providers for their initial appointment. This intervention is supported by findings from a retrospective cohort study that took place from 2013 to 2017 at a RWHAP-funded clinic. In addition to significantly decreasing the time between referral and initial visit, clients who saw a pharmacist also experienced shortened time to antiretroviral therapy initiation and viral suppression compared to those who only saw non-pharmacist providers.
  • Best Practices Compilation
    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.
  • Best Practices Compilation

    Caracole, an AIDS Service Organization, uses three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and motivational interviewing. Clients in permanent supportive housing had high rates of viral suppression, exceeding Caracole's goal of 75%.

  • Best Practices Compilation
    The AIDS Institute is committed to promoting, monitoring, and supporting the quality of clinical services for people with HIV in New York State. The Adolescent Quality Learning Network (AQLN) is a collaborative of 16 HIV Adolescent/Young Adult Specialized Care Center (SCC) programs. In collaboration with the AIDS Institute, SCC providers selected a quality improvement project aimed to raise viral suppression rates by improving access to mental health services.
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    A broad population of men who have sex with men (MSM) reached viral suppression through intensive case management by applying tools and lessons learned in the Center for Quality Improvement Innovation end+disparities ECHO Collaborative.
  • Best Practices Compilation
    INFINI-T is a program designed to reach young transgender women of color with HIV and retain them in care through peer advocates who provided case management. These peer advocates facilitated social support sessions with the goal of alleviating the negative impacts of psychosocial factors like history of trauma, stigma, and discrimination. Clients were more likely to be virally suppressed and retained in care after 12 months of participating in the intervention.
  • Best Practices Compilation
    Three participating clinics—MetroHealth, the University of Kentucky Bluegrass Care Clinic, and Centro Ararat—participated in a RWHAP Part F SPNS initiative from 2016 through 2019 to implement integrated buprenorphine treatment and HIV care. Research has shown that care integration improves HIV outcomes, engagement in substance use disorder treatment, and quality of life for people with HIV. Clients participating in this intervention received integrated opioid use disorder (OUD) and HIV care to improve retention in care, viral suppression, and engagement in OUD treatment.
  • Best Practices Compilation
    By integrating comprehensive HIV medical care with addiction services and medication protocols for substance use disorder (SUD), clients with HIV and SUD saw improvements in retention in care and viral suppression.
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    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.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    Gay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
  • Best Practices Compilation
    LINK LA is a 12-session, 24-week peer navigation intervention for people with HIV who are scheduled to be released from incarceration. LINK LA peer navigators focus on behavioral changes that promote medication adherence and retention in care, while providing social support and facilitating communication with medical providers. LINK LA showed improvements in linkage to and retention in HIV care and viral suppression among people with HIV re-entering the community after incarceration.
  • Best Practices Compilation
    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.
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    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.
  • Best Practices Compilation
    The RWHAP Part F SPNS program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.
  • Best Practices Compilation
    The Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    Multicomponent Support Strategies was implemented during the COVID-19 pandemic shelter-in-place order. Ward 86 Clinic staff and trained volunteers provided outreach to 1,816 clients about the availability of various support, including in-person medical care, mental health and substance use services, medication delivery, food assistance, housing support services, and Positive Health Onsite Program for Unstably Housed People (POP-UP), a low-barrier high-intensity drop-in program. Results showed that viral suppression increased at a faster rate after Multicomponent Support Strategies was implemented.
  • Best Practices Compilation
    The New York City HIV Care Coordination Program is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. Multiple evaluations of the program consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.
  • Best Practices Compilation
    Fenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the RWHAP Part F SPNS initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.
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    OPT-In For Life is a social media-based intervention that promotes advancement along the HIV care continuum for young adults (ages 18 to 34) with HIV. During the 18-month intervention, OPT-In For Life used multiple social media platforms and a mobile application to provide HIV-related and positive lifestyle resources. Young adults enrolled in OPT-in For Life demonstrated improved retention in HIV care and higher rates of viral suppression after participation.
  • Best Practices Compilation
    The University of Pittsburgh Medical Center, Center for Care of Infectious Diseases, Pittsburgh Area Center for Treatment (PACT) began implementing the Food Assistance Program in August 2017 to serve as a supplemental resource for people with HIV receiving care who experience food insecurity. The program helps bridge gaps in Supplemental Nutrition Assistance Program (SNAP) benefits and monthly food costs while promoting access to healthy foods and retention in HIV care.
  • Best Practices Compilation
    The Patient-Centered HIV Care Model (PCHCM) integrates the services of community-based HIV specialized pharmacists and HIV medical providers to deliver patient-centered care for people with HIV. PCHCM expands upon the medication therapy management model by including information sharing between partnered pharmacy and clinic teams; collaborative medication-related action planning between pharmacists, medical providers, and patients; and quarterly follow-up pharmacy visits. Patients participating in the intervention had improved retention in care and viral suppression rates.
  • Best Practices Compilation
    University Health uses peers and patient navigators to provide support, reduce barriers, and improve linkage and retention to care for women and youth with HIV. Two peers with lived experience were hired as Outreach Specialists to spearhead the program, encourage medication adherence and use of services, and provide mentoring. The intervention was successful in moderately improving the numbers of clients linked to care, retained in care, and virally suppressed.
  • Best Practices Compilation
    From 2016 through 2019, three clinics—AIDS Care Group, Howard Brown Health, and Meharry Medical College—participated in a RWHAP Part F SPNS DEII initiative to implement peer linkage and re-engagement interventions for women of color with HIV. Integrating peers into HIV primary care teams has been effective in better engaging women of color in care.
  • Best Practices Compilation
    POP-UP provides low-barrier comprehensive HIV primary care, substance use services, mental health services, and case management to people who are homeless and unstably housed with the goal of retaining clients in care and improving viral suppression. Among POP-UP participants, 44% who were unstably housed and not virally suppressed at the start of the study were virally suppressed 12 months after enrollment.
  • Best Practices Compilation
    Positive Care Center implemented the Rapid Access program in 2018, providing clients with ART on the same day as HIV diagnosis. Pharmacists, embedded within Positive Care Center’s care team, help clients with their treatment plans and adherence strategies. Over 90% of clients served through Rapid Access in 2021 received ART on the same day as diagnosis, and 82% of clients were retained in care at six months.
  • Best Practices Compilation
    The Positive Peers app motivates youth and young adults with HIV to stay engaged in HIV care through self-management tools and virtual support. Although specific outcomes vary by age group, individuals who used the app were more likely to attend their medical appointments, receive labs, and reach viral suppression.
  • Best Practices Compilation
    PositiveLinks is a mobile platform deployed by clinics or community-based organizations to connect people with HIV to a digital support community. The client-facing app helps people with a new diagnosis of HIV become engaged in care and helps people at risk of being lost to care overcome barriers related to geographic or social isolation. From the app, people can access Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant patient dashboards, secure messaging, and patient lab records. People who used PositiveLinks had increased rates of retention in care and viral suppression.
  • Best Practices Compilation
    The PC4H initiative employs a mobile app and a digital literacy workshop to improve engagement, retention in care, and medication adherence for young people with HIV. These strategies aim to reach young people who are disproportionately affected by HIV, including young men who have sex with men, young transgender women, and youth of color, with a focus on serving people who know their status but are inconsistently engaged in care. Developed by Children’s Hospital of Philadelphia and Philadelphia FIGHT, PC4H was evaluated through the RWHAP Part F SPNS Social Media Initiative. The evaluation found that PC4H had positive impacts on retention in care and viral suppression.
  • Best Practices Compilation
    The University of Mississippi Medical Center implemented a Postpartum Retention and Engagement Quality Improvement Initiative in 2017 to improve linkage to care, retention in care, and viral suppression among postpartum women with HIV. This intervention uses a combination of care coordination, printed materials, case management services, and improved collaboration and coordination between the Adult Special Care Clinic, which provides comprehensive HIV medical care, and a Perinatal HIV Program. The comprehensive intervention significantly improved retention in HIV care and increased viral suppression at both six and 12 months postpartum.
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    Project CONNECT uses linkage coordinators to effectively engage people in HIV medical care. It focuses on people with newly diagnosed HIV or people with HIV who are transferring their care or have been out of care. AIDS Taskforce of Greater Cleveland implemented Project CONNECT as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Project CONNECT was successful in increasing the number of clients retained in HIV care and who reached viral suppression.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    The Maricopa Jail Project was implemented by five jails to decrease the wait time between incarceration and/or diagnosis to the start of treatment, and to better support clients to reach viral suppression. Maricopa hired a nurse practitioner to manage access and case manage across the jail system. The initiative was successful in increasing the number of clients who were virally suppressed.
  • Best Practices Compilation
    The Ruth M. Rothstein CORE Center launched Proyecto Promover to decrease HIV testing-related stigma, increase awareness of HIV status, and increase early linkage to and retention in care among Mexicanos with HIV. The program operates at the community level through social marketing, educational talks, networking, and testing. On the individual level, Proyecto Promover uses one-on-one conversations to identify and overcome barriers related to care engagement and retention. Evaluation showed promising rates of HIV testing, retention in care, and viral suppression.
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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.
  • Best Practices Compilation
    The Rapid ART Start Protocol focuses on helping veterans with a new HIV diagnosis access ART and comprehensive treatment as soon as possible. A retrospective cohort study showed positive outcomes, including decreases in the time to first appointment, the time to ART initiation, and the time to reach viral suppression. In addition, patients receiving the intervention were more likely to reach viral suppression compared to patients seen pre-intervention at the same clinic.
  • Best Practices Compilation
    Southeast Mississippi Rural Health Initiative, Inc., a network of community health centers serving Southern Mississippi, uses data-driven quality improvement techniques to identify youth who are not virally suppressed or have missed appointments. Medical case managers use a client checklist to identify and address barriers to antiretroviral therapy (ART) and medical care adherence. They also use a health literacy visual illustration tool to help youth understand the effects of ART on viral suppression. The intervention strategy was successful in improving viral suppression rates for youth.
  • Best Practices Compilation
    Routine Universal Screening for HIV (RUSH) provides non-medical case management services, opt-out HIV testing, and linkage to care for emergency department patients. The intervention automatically screens patients for HIV if they are aged 16 years or older, are having an IV inserted, or are having blood drawn for other reasons, unless the patient opts out. RUSH provides access to testing earlier in disease progression, bridging disparities that primarily impact people of color. It also promotes linkage to and retention in care for those with a positive HIV test result. Clients with a positive HIV test in the emergency department who had a prior diagnosis of HIV were more likely to be retained in care and to reach viral suppression.
  • Best Practices Compilation
    SBIRT is designed to screen clients for drug and alcohol use, educate clients on the risks of use, and connect them to substance use treatment services if necessary. SBIRT is an evidence-informed intervention that has been adapted by HIV experts in collaboration with community members to improve health outcomes among people with HIV. Two sites implemented SBIRT as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Among the clients enrolled in SBIRT, the percentage with a prescription of antiretroviral therapy (ART) and who reached viral suppression both increased significantly.
  • Best Practices Compilation
    Seeking Safety helps people who have experienced trauma and/or substance use disorder gain safe coping skills through a flexible 12-session intervention. The University of California, San Diego Mother Child Adolescent HIV Program and the Multicultural AIDS Coalition implemented Seeking Safety as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Participants had higher rates of retention in care and viral suppression after 12 months of the intervention.
  • Best Practices Compilation
    This nine-month program tailored services for people with HIV by bundling three to five evidence-informed care strategies for each client, such as mental health referrals, transportation assistance, appointment reminders, and pill boxes. A primary care physician, case manager, and pharmacist coordinated with each client to address their specific needs. After the intervention, 70.1% of previously non-suppressed clients were virally suppressed.
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    Five clinics implemented Tailored Motivational Interviewing (TMI) to better serve young people with HIV as part of a RWHAP Part F SPNS initiative. Motivational interviewing is a well-documented approach to engage youth in care and facilitate behavior change in a variety of contexts. Clients participating in TMI received integrated HIV medical care and TMI, and demonstrated improved engagement in care and health outcomes.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    Taking Care of Me is a video- and poster-based intervention to promote prompt ART initiation and medication adherence for people with HIV. The video and posters are designed for use in HIV clinics, drawing on the example of similar initiatives launched in public health clinic waiting rooms that aim to reduce incidence of sexually transmitted infections. A trial testing the efficacy of Taking Care of Me found that clients exposed to the video were more likely to be prescribed ART and reach viral suppression.
  • Best Practices Compilation
    TAVIE Red is a mobile application that aims to improve retention in HIV care and address social determinants of health. It helps case managers connect with clients and uses gamification, a technique with elements of gameplay such as earning points and completing quests, to increase engagement with HIV care and psychological self-care management tools. TAVIE Red participants overwhelmingly reported that the technology helped them manage their HIV diagnosis.
  • Best Practices Compilation
    The University of Nebraska Medical Center/Nebraska Medicine (UNMC/NM) Specialty Care Center (SCC) is the largest provider of comprehensive HIV care—including primary and HIV-focused medical services as well as multiple support services—in Nebraska. In March 2020, at the onset of the COVID-19 pandemic, the clinic integrated telehealth into its care delivery model to continue serving patients beyond the clinic structure, and developed algorithms that allowed any team member to quickly identify a patient's eligibility for a telehealth visit. The algorithms include the date of the most recent office visit, stability of HIV disease, most recent viral load and CD4 count, and antiretroviral therapy (ART) refill histories as a proxy for medication adherence. Overall, viral suppression rates remained high for all patients regardless of visit type, indicating that telehealth is a successful alternative to in-person visits for providing HIV care.
  • Best Practices Compilation
    Through the Test & Treat Rapid Access (TTRA) Program, clients with a new HIV diagnosis in Miami-Dade County can access ART, receive other services and counseling, start enrolling in RWHAP, and connect to HIV primary care during the initial visit. At Borinquen Health Care Center, one of the clinical sites participating in TTRA, 76% of clients were virally suppressed within three months of receiving a rapid ART start, and 95% were retained in care for 12 months.
  • Best Practices Compilation
    The Test and Treat initiative, implemented by Oklahoma State University, connects people to antiretroviral therapy (ART) within 14 days of HIV diagnosis through streamlined intake and initial clinic visit protocols and 30-day medication starter packs. Participants in Test and Treat are linked to care and reach viral suppression sooner, and are more likely to be retained in care, as compared with people in standard care.
  • Best Practices Compilation
    Text Me, Girl! is a text messaging intervention that aims to improve linkage to and retention in HIV care, increase adherence to HIV medications, and improve viral suppression and other health outcomes among transgender women ages 18–34 years. The intervention supports young transgender women with HIV, particularly those experiencing barriers to care such as periods of homelessness and/or incarceration, substance misuse, or engaging in sex work. Text Me, Girl! participation was associated with statistically significant improvements in antiretroviral therapy uptake and adherence, and self-reported viral suppression.
  • Best Practices Compilation
    The Text Messaging Intervention to Improve Antiretroviral Adherence among HIV-Positive Youth (TXTXT) is designed to keep young people, particularly young, Black, gay, bisexual, same-gender loving, and other men who have sex with men, engaged in HIV medical care, by delivering personalized, daily, interactive text messages that remind them to take their antiretroviral therapy as prescribed. Two sites implemented TXTXT as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. The intervention resulted in a statistically significant improvement in engagement in HIV care.
  • Best Practices Compilation
    The Alexis Project used social network recruiting and engagement, peer navigation, and contingency management to reach and engage transgender women of color with HIV who were not engaged in HIV care. Participation in the 18-month intervention improved linkage to care and viral suppression.
  • Best Practices Compilation
    The Max Clinic, located within the University of Washington’s Harborview Medical Center complex in Seattle, offers walk-in services and incentives to clients reengaging in HIV care, especially those who have not been well served by the traditional health care model—including clients who are experiencing homelessness, or who have mental health and substance use issues. The Max Clinic offers rapid antiretroviral therapy, incentives, a flexible clinical model, and access to comprehensive support services. Max Clinic clients were significantly more likely to reach viral suppression after 12 months than a comparable control group.
  • Best Practices Compilation
    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 adherence strategies to support treatment adherence and viral suppression among people with HIV. A two-year demonstration project evaluation showed a significant increase in the proportion of clients who were virally suppressed from 39% to 62%.
  • Best Practices Compilation
    The Village Project is an intensive case management-based intervention that harnesses peer navigation and integrated behavioral health services to improve the health outcomes of young Black gay, bisexual, and men who have sex with men. The Village Project was associated with increased retention in care and viral suppression.
  • Best Practices Compilation
    Trauma-Informed Approach & Coordinated HIV Assistance and Navigation for Growth and Empowerment (TIA/CHANGE) was developed by HIV experts in collaboration with community members to improve health outcomes among people with HIV. Using a strength-based approach to HIV service provision, TIA/CHANGE offers guidance and structure for an organization to become trauma-informed. TIA/CHANGE includes enrollment of clients in trauma-informed intensive case management services. The Alaska Native Tribal Health Consortium implemented TIA/CHANGE as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Among clients participating in TIA/CHANGE there were improvements in prescription of ART and viral suppression.
  • Best Practices Compilation
    Bienestar developed TransActivate to improve timely engagement and retention in HIV care among Latina transgender women. Linkage coordinators/peer navigators use a strengths-based approach to help clients reach their goals of entering and staying in medical care to ultimately reach viral suppression.
  • Best Practices Compilation
    The Rutgers New Jersey Medical School created a transgender health program and integrated it into their Infectious Disease Practice. The program conducted community outreach to engage transgender men and women in care, trained all staff on gender affirming care, hired transgender staff, provided gender affirming care and hormone treatments onsite, and offered mental health support to patients.
  • Best Practices Compilation
    T.W.E.E.T. aims to engage transgender women in HIV care by combining weekly peer-based education and discussion groups, leadership training, community building, and the provision of supportive services. Three sites implemented T.W.E.E.T. as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Clients had improved outcomes across the HIV care continuum 12 months after enrollment in T.W.E.E.T.
  • Best Practices Compilation
    Transitional Care Coordination (TCC) connects people with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails.
  • Best Practices Compilation
    MacGregor Infectious Diseases, a hospital-based clinic affiliated with the Hospital of the University of Pennsylvania, implemented a multidisciplinary approach to strengthen outreach to clients and improve care retention. As compared to clients in standard care, clients served with the multidisciplinary approach had higher rates of retention in care, particularly among clients who were not virally suppressed.
  • Best Practices Compilation
    Virginia Rapid Start launched with HIV care providers across the state with goals to initiate ART for clients within 14 days of HIV diagnosis and to improve access to, and retention in, high-quality HIV care and support services. Through Virginia Rapid Start, providers initiated ART medications within an average of four days of HIV diagnosis, as compared with the statewide average of 28 days. Virginia Rapid Start clients had higher rates of viral suppression compared to both the RWHAP Part B overall and Virginia overall. The success of Virginia Rapid Start led VDH to expand the program to the entire Virginia RWHAP Part B.
  • Center for Innovation and Engagement
    Clinical Decision Support System (CDSS) that generates alerts in electronic medical records to notify HIV outpatient providers of suboptimal follow-up, virologic failure, and laboratory toxicity.
  • Best Practices Compilation
    Viviendo Valiente aims to reduce ethnic disparities in HIV care and outcomes by providing culturally responsive services to the Latino/a community, specifically to people of Mexican descent. It is a multi-level intervention, featuring individual-, group-, and community-level activities, that links people to HIV care, offers HIV education and health literacy in group sessions, and promotes community-level testing for HIV and other sexually transmitted infections (STIs). Viviendo Valiente had positive impacts on HIV testing, retention in care, viral suppression, and client satisfaction.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    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.
  • Best Practices Compilation
    The YGetIt? Program engaged youth and young adults with HIV in care through three components: a health management mobile application (GET!), Peer Engagement Educator Professionals (PEEPs), and a graphic serial (Tested). Tested received over 200,000 views, and viral suppression rates among YGetIt? participants increased from 79% to 86% over the course of the program.

Resources

Webinars

Conference Presentations

Technical Assistance

  • Capacity building for the RWHAP community to navigate the changing health care landscape and help people with HIV to access and use their health coverage to improve health outcomes. Project period: 2022-2025.
  • The central hub of the AETC Program, the clinical training arm of the RWHAP, through HIV curricula, technical support to regional AETCs on practice transformation and best practices, and housing of all AETC-developed tools for HIV clinical staff. Project period: 2019-2024.
  • Clinician consultation on HCV management, HIV management, perinatal HIV/AIDS, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis, substance use. Project period: 2016-2025.

  • The AETC Program offers clinician education and tailored capacity-building assistance. Project period: 2019-2024.
  • Initiative documenting best practice strategies and interventions that have been shown to improve HIV outcomes in a "real world" setting and can be replicated by other programs. Project period: 2021-2024.