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.
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.
Resources 49
Best Practices
- Best Practices Compilation
- Best Practices CompilationHispanic 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.
- Best Practices Compilation2BU 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.
- Best Practices CompilationBuprenorphine 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.
- Best Practices CompilationCollaborative 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.
- Best Practices CompilationTen 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.
- Best Practices CompilationE-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 CompilationThis 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 CompilationThe 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 CompilationHealthy 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 CompilationThe 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 CompilationHHOME 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 CompilationThe 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.
- Best Practices CompilationA 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 CompilationThree 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 CompilationBy 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.
- Best Practices CompilationJumpstART 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 CompilationLA 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 CompilationGay 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 CompilationLINK 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 CompilationLink-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.
- Best Practices CompilationThis 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 CompilationThe 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 CompilationThe 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 CompilationMORE 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 CompilationThe 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 CompilationFenway 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.
- Best Practices CompilationThe 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 CompilationThe 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 CompilationUniversity 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 CompilationFrom 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 CompilationThe 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 CompilationPositiveLinks 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 CompilationThe 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 CompilationThe 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.
- Best Practices CompilationProject 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.
- Center for Innovation and EngagementClinical 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.
Resources
- National Clinician Consultation Center
Healthcare providers can receive no-cost expert clinical consultation in HIV prevention & care, HCV treatment, and substance use management.
- University of Washington
Online clinician training platform with evidence-based core competency training on HIV prevention, screening, diagnosis, care, and key populations.
- U.S. Department of Health and Human Services
Federal guidelines for treatment, prevention and care of HIV disease, opportunistic infections, and common co-infections.
- Technical Assistance Provider Innovation Network (TAP-in)Guide for EHE jurisdictions on what they can do to enhance implementation of long-acting injectable antiretroviral therapy.
- ACE TA Center
- ACE TA Center
Seri afich ki vize konsomatè yo se pou deklanche konvèsasyon ant konsomatè ak founisè yo osijè tr - Technical Assistance Provider Innovation Network (TAP-in)What HIV care providers can do to create a rapid ART program to get HIV clients on treatment the same day as a diagnosis.
Webinars
- SPNS HIV/HCV Data-to-Care InitiativeReview of the data to care project and lessons learned on HCV micro-elimination activities from the Arizona Department of Health Services.
- Technical Assistance Provider Innovation Network (TAP-in)Learn how to improve messaging about HIV prevention and care to improve acceptance of services among all Black women.
- Technical Assistance Provider Innovation Network (TAP-in)In 2021, the U.S. public was introduced to a bi-monthly injectable form of PrEP, which stands for Pre-Exposure Prophylaxis.
- Technical Assistance Provider Innovation Network (TAP-in)Review of concept of status neutral (access to HIV services regardless of HIV status).
Conference Presentations
HIV 101: Fundamentals of HIV Pathogenesis, Antiretroviral Therapy Initiation, & Primary Care for PWH
Presenters:
Gandhi, Saag, Thompson
2021 Ryan White HIV/AIDS Program Clinical Conference