Housing & Homelessness

Collection of implementation guides on evidence-informed best practices in HIV care delivery.

Workbooks describing ways to help connect people living with HIV/AIDS to medical care. Estos cuadernos describen la manera de asistir a conectar personas que viven con VIH/SIDA con el sistema médico.  

Intervention using three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and Motivational Interviewing.

HHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.

KC 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.

COVID-19 adjustments developed by Ryan White HIV/AIDS Program recipients.

Best practices (and extensive resource links) for integrating into medical care teams the non-medical staff called Navigators.

Review of strategies for housing vulnerable populations in tight housing markets.

Insights from a HRSA SPNS initiative on care coordinator/patient navigation interventions for vulnerable populations.

Study examining models of integration and coordination of housing assistance services and HIV care.

Avenue 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.

SSRP is a client, provider, and system levels intervention to rapidly connect PLWH recently released from jail/prison to medical, housing, and employment services using a Peer Community Reengagement Specialist model.

Coordination of client services for six months and transitioning clients to the jurisdiction's case management system after completion of the program. Acuity scores determine clients’ case management paths.

Short-term intensive case management services to link clients to housing, employment, and health care services provided by a team comprised of a Peer Care Navigator, Housing Navigator, and an Employment Navigator.

Smart Care Management data-driven/IT model (e.g., patient portal, real-time dashboard for agencies) to enhance utilization of existing health, housing, and employment services.

The intervention integrated supportive employment services, housing services, and HIV care for clients receiving case management services and with unmet housing and employment needs. Evaluation of the program showed improvements in employment rates, participant confidence in being able to hold onto a job, household median income, participants’ living situations, and self-perception of homelessness status.

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.

Coordination of health care with housing and employment services through regular meetings, formal agreements, and a Linkage Coordinator.

Partnership 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. 

Care coordination to link clients to services by assessing client needs, barriers, and stages of change, guided by electronic health records and a modified stages of change tool used to assess housing & employment stages of change.

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.

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%.

KC Life 360’s same-day intake, informed consent, and one-on-one with an Employment Career Specialist generates awareness of services and benefits across provider networks.

Expanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.

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.

The Leveraging Housing Opportunities to Promote Retention in Care for People with HIV program in New York City offers three types of housing-related supportive services.

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.

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.

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.

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.

Housing first model to help people with HIV address their housing instability while working towards obtaining employment and maintaining consistent medical care. Every patient completes an individual service plan, developed in partnership with their case manager.

Through the Practice Transformation Project, the Native American Community Clinic and Midwest AIDS Education and Training Center developed strategies to increase testing and linkage to care within the American Indian/Alaska Native population, and for those who inject drugs and are experiencing homelessness. These ongoing efforts have increased HIV testing rates by 10 percentage points through harm reduction, community outreach, and culturally sensitive strategies.

Clients are enrolled into a low barrier program that provides immediate and critical housing crisis intervention, including in-housing employment services and ongoing intervention services to secure permanent housing and maintain access to HIV primary care.

Avenue 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.

Yale 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.

Project Vogue provided community-based care coordination, HIV care, and behavioral health services to Black men who have sex with men (MSM) within New York City’s House & Ball community to address the unique cultural barriers that Black MSM experience when trying to access care. Project Vogue participants were linked to behavioral health services as well as to non-clinical supportive services, such as food and housing assistance.

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.

Housing and employment services include a Job Club to provide a supportive environment and training for participants. 

Information and training resources for various community development programs under the auspices of HUD, including HOPWA, Housing Opportunities for Persons with AIDS.

Medical case management acuity tool to assess severity of needs of clients living with HIV in various areas of functioning and categories of severity.

Review of the impact of unstable housing and homelessness on each step of the HIV care continuum and insights on improving care engagement and health outcomes at each stage. 

Webinars and briefs on delivery of HIV care to persons with unstable housing.

Webinar series featuring HIV care innovations developed under HRSA SPNS projects.

Insights on understanding and leveraging of existing housing service systems to better serve people with HIV experiencing unstable housing.