Collection of implementation guides on evidence-informed best practices in HIV care delivery.
People with HIV often have a range of medical and support needs that may be met more efficiently when agencies work together. Collaboration takes various forms, like referral arrangements, planning (e.g., sharing of data, participation in planning), common fiscal/grants management processes, single intake/eligibility systems, and sharing/adoption of best practices in HIV service delivery.
Best Practices
- Center for Innovation and Engagement
- HRSA Bureau of Primary Health Care (BPHC), Centers for Disease Control and Prevention (CDC)Toolkit to help Health Centers expand the provision of HIV services.
- IHIPThis guide details components of a program establishing a medical-community partnership to facilitate a linkage to care program reengaging HIV clients in care and decreasing missed appointments.
- IHIPHHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.
- IHIPKC Life 360 is an employment-focused intervention that utilizes the intersection between employment services, HIV care and treatment, and housing to improve health outcomes of people with HIV.
- IHIPThe Maricopa County Jail Project was implemented by five jails and uses a nurse practitioner to manage service access and case management across the jail system.
- SPNS Latino Access Initiative, UCSF Center for AIDS Prevention Studies
Monographs describing interventions for the engagement and retention of Latinos in HIV care.
- HRSA HIV/AIDS Bureau (HAB)
Examination of potential areas for bi-directional sharing between the U.S. Ryan White HIV/AIDS Program (RWHAP) and the President’s Emergency Plan for AIDS Relief.
- HRSA/SPNS Workforce Initiative
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 Transgender Women of Color Initiative
Innovative models for linking and retaining transgender women of color in HIV care.
- Center for Advancing Health Policy and Practice
Insights from a HRSA SPNS initiative on care coordinator/patient navigation interventions for vulnerable populations.
- SPNS Systems Linkages Project
Insights from a multi-state demonstration and evaluation of innovative models for linkages to and retention in HIV care.
- Boston University School of Social Work Center for Innovation in Social Work and Health
SPNS innovative and replicable HIV service delivery models using HIV+ peers.
- AIDS Alliance for Children Youth and Families
Resource for programs interested in developing or expanding outreach services to identify HIV-positive youth and engage and retain them in care.
- The HIV, Housing & Employment ProjectAvenue 360 Health & Wellness offers a medical home for patients and AIDS Foundation Houston coordinates employment training and resources. These agencies believe that coordination is the key to breaking down barriers to health care in their community.
- Center for Innovation and EngagementThe Clinic-Based Surveillance-Informed (CBSI) intervention combines clinic and health department surveillance data to identify people with HIV who are out of care and re-engage and retain them in HIV care.
- The HIV, Housing & Employment ProjectCoordination of health care with housing and employment services through regular meetings, formal agreements, and a Linkage Coordinator.
- The HIV, Housing & Employment ProjectPartnership between employment services and Ryan White HIV/AIDS Program providers to foster case coordination among medical care and social service providers, including a screening and referral system for housing and employment needs and services individualized for specific patient needs.
- 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 CompilationOne Stop Career Center of Puerto Rico (OSCC-PR) implemented Pay it Forward to increase workforce capacity to connect Puerto Ricans with HIV to community-based HIV care and social supports following release from jail. Pay it Forward included training of OSCC-PR staff in the Transitional Care Coordination model. Eighty percent of clients who were supported by Pay it Forward in Puerto Rico were still in HIV care 12 months after release.
- 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 CompilationAvenue 360 Health and Wellness, a Federally Qualified Health Center, and AIDS Foundation Houston, a community-based AIDS Service Organization, implemented Project CORE. This intervention aimed to improve health outcomes for people with HIV through the coordination of supportive employment and housing services. Through Project CORE, 39% of participants were placed in housing and 39% gained employment.
- Best Practices CompilationYale Community Health Care Van and Clinic, and Liberty Community Services, Inc., empowered clients to set and achieve employment and housing goals, as well as strengthened the ability of community-based organizations to provide related services. This initiative known as Project HERO was implemented between 2017 and 2020 as part of the HIV, Housing, and Employment SPNS initiative.
- Center for Innovation and EngagementProject to increase HIV awareness through outreach and testing events on college campuses and in the larger community through partnerships and care linkages.
- Best Practices CompilationThe 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 CompilationThe Virginia Commonwealth University implemented a clinical quality improvement project to increase linkage to HIV medical care within 30 days and initiation of antiretroviral therapy (ART) at the first visit by making “Rapid Access” appointments available each week for people with newly diagnosed HIV.
- Best Practices CompilationThe 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 CompilationTransitional 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 CompilationVirginia 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.
Resources
- In It Together
Health literacy training initiative to help health professionals incorporate health literacy approaches into their services.
- HRSA HIV/AIDS Bureau (HAB), IHIP
Tools on ways to expand/replicate innovative models of oral health care for people with HIV.
- HRSA HIV/AIDS Bureau (HAB)
Toolkit for implementing a program to support HIV-positive youth transitioning from adolescent to adult HIV care.
- Yale University School of Medicine
Guide on how to implement an opt-out HIV testing program in a jail setting.
- HRSA/SPNS Workforce Initiative
A stepwise practice transformation approach for health care organizations seeking to add HIV care or to increase services for people with HIV.
- HRSA HIV/AIDS Bureau (HAB)
Guide to best practices for enhancing services to youth with HIV to better outcomes in both retention and viral load suppression.
- IHAP TA Center
Examples of sections within a care/prevention integrated plan (epidemiologic overview; continuum; resource inventory; assessing needs; data; plans; collaboration and involvement). Section in the Integrated HIV Prevention and Care Planning Online Resource Guide.
- IHIP
Insights on ways that HIV care programs have improved health outcomes along the HIV care continuum.
- Boston University School of Social Work Center for Innovation in Social Work and Health
Cross-disciplinary training curriculum to increase knowledge and awareness of the relationship between HIV infection and substance use. Also available in Spanish (Version en español).
Training Modules
The five stages of preparing a care/prevention integrated plan (organize and prepare; prioritize; implement; monitor and make improvements; communicate and share progress). Section in the Integrated HIV Prevention and Care Planning Online Resource Guide.
- HRSA HIV/AIDS Bureau (HAB)
Resources on HCV treatment among HIV coinfected patients.
- IHIPTested resources for implementing jail linkage programs and assisting organizations in expanding their current jail work. Includes a manual, curriculum, fact sheets, and webinars.
Webinars
- HRSA HIV/AIDS Bureau (HAB)
Pre-application webinars for Notice of Funding Opportunity (NOFO) announcements from HRSA's HIV/AIDS Bureau for the Ryan White HIV/AIDS Program (RWHAP).
- IHIPWebinar series featuring HIV care innovations developed under HRSA SPNS projects.
- IHIPReview of Practice Transformation/Transformative Models (PTMs) to improve delivery of HIV services.
Conference Presentations
Collaborative Research
Presenters:
John Sapero, Tom Butcher, Nancy Kingwood
2022 National Ryan White Conference on HIV Care & Treatment
Marshall University School of Medicine
Presenters:
Kara Willenburg, Melanie Nace, Anndrea Rogers
2022 National Ryan White Conference on HIV Care & Treatment
Tarrant County HIV Administrative Agency
Presenters:
James d'Etienne, Thomas Donohoe, Douglas White, Lisa Muttiah, Afiba Agovi
2022 National Ryan White Conference on HIV Care & Treatment
Sustainable Strategies for Strengthening Systems of Care for People with HIV and Opioid Use Disorder
JSI Research & Training Institute
Presenters:
Molly Higgins-Biddle, Juli Powers, Isabel Evans, Liz Sweet
2022 National Ryan White Conference on HIV Care & Treatment
HRSA HIV/AIDS Bureau
Presenters:
Ruchi Mehta, AJ Jones, Debbie Isenberg, Leslie Frank, Elisabeth Meyer, Isabella Warmbrunn, Claire Novotny, Gretchen Regier, Weston Stokey
2022 National Ryan White Conference on HIV Care & Treatment