Collection of implementation guides on evidence-informed best practices in HIV care delivery.
Integrated Care
Some care delivery models are designed to address multiple care needs in addition to HIV. Conditions include substance abuse, hepatitis, attention to HIV prevention and care, and services for specific populations (e.g., youth, women). Integrated care can be achieved by, for example, a mix of staff and collaboration across service departments.
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.
- IHIPIntervention to create a safe place for delivering stigma-free, trauma-informed and integrated HIV, addiction medicine and behavioral health services under a single roof.
- 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.
- 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.
- IHIP
Implementation guide for HIV providers on addressing the unique needs of women of color living with HIV.
- HRSA HIV/AIDS Bureau (HAB)
Resources to assist Ryan White HIV/AIDS Program and other HIV clinics to integrate buprenorphine programs within primary care settings.
- 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.
- Best Practices CompilationTo 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.
- 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 CompilationExtramural dental clinics implemented the medical home model, with integrated trauma-informed care, to expand oral health care services for people with HIV, and saw increases in referrals from partner organizations and the number of new clients.
- 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.
- Evidence-Informed Interventions (E2i)Integrated buprenorphine treatment is an evidence-informed intervention to safely reduce opioid use disorder and improve HIV health outcomes among people with HIV.
- Center for Innovation and EngagementIntervention consisting of on-site buprenorphine treatment guided by an experienced HIV physician who is trained to incorporate motivational interviewing techniques into routine medical visits to provide substance use behavior counseling.
- Dissemination of Evidence Informed-Interventions Project (DEII)Buprenorphine intervention informed and adapted from the best practice findings of a past SPNS initiative that yielded successful HIV care continuum outcomes among client participants.
- 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 CompilationThe University of California San Francisco, San Francisco General Hospital HIV Clinic developed a care model to enhance access to hepatitis C virus (HCV) treatment among people with HIV by co-locating care and creating a multidisciplinary team. Developed as part of the RWHAP Part F SPNS Hepatitis C Treatment Expansion Initiative, this model of care led to a considerable decrease in the number of people with HIV who were coinfected with HCV among the patients served by San Francisco General Hospital during the 2010 and 2011 demonstration years.
- Best Practices CompilationThis referral-based oral health model used dental navigators to connect clients to a large network of dentists, which facilitated scheduling of appointments.
Documents
- In It Together
Health literacy training initiative to help health professionals incorporate health literacy approaches into their services.
- 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 HIV/AIDS Bureau (HAB)
Methods that involve persons with HIV to help link others into care.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderTerms describing key concepts and components of the HIV and opioid use disorder (OUD) care and treatment systems.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderConsiderations for how state agency staff can develop and maintain an accessible, HIV and opioid use disorder (OUD) service inventory.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderTool to support state health departments in identifying opportunities for enhanced coordination between HIV and OUD funding and service provision.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderDescription of the role of peers in care for people with HIV and OUD and how a state’s Medicaid program can fund peer services.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderTool for addressing stigma in relation to systems-level policies and practices that can improve individual level interventions.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderGuide on how to coordinate HIV/HCV treatment with substance use treatment and recovery.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderDescription of two states' approaches to building and supporting an HIV and opioid use disorder (OUD) workforce and considerations for investing in a collaborative workforce.
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderThis library includes various substance use screening tools. These tools are intended to provide a valid and reliable snapshot of a client 's substance use, which may point toward a need for further assessment and specialized support.
- HRSAWhat are the key elements of your intervention that other providers should be sure to implement?
- Strengthening Systems of Care for People with HIV and Opioid Use DisorderDiscussion guide to elicit a conversation about language, stigma, and discrimination as a means of strengthening care systems.
- 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.
- 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).
Trainings
- HRSA HIV/AIDS Bureau (HAB)
Resources on HCV treatment among HIV coinfected patients.
- Center for Engaging Black MSM across the Care Continuum
Provider training on the delivery of HIV health care services for black men who have sex with men to enhance engagement/retention in care.
- 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).
- IHAP TA CenterOverview of the benefits and challenges of implementing a status neutral approach and jurisdiction experiences (Oregon, San Antonio).
- IHIPWebinar series featuring HIV care innovations developed under HRSA SPNS projects.
- IHIPInsights on developing and disseminating implementation tools and resources to support the uptake and replication of innovative HIV care strategies.
- Technical Assistance Provider Innovation Network (TAP-in)Recordings of the TAP-in webinars on topics critical to the Ending the HIV Epidemic Initiative.
- IHIPReview of Practice Transformation/Transformative Models (PTMs) to improve delivery of HIV services.
Conference Presentations
Boston University
Serena Rajabiun, Thomas Byrne, Erik Moore, Silvia Moscariello
2022 National Ryan White Conference on HIV Care & Treatment
Greater Lawrence Family Health Center
Christopher Bositis, Sandra Silva, Amy Bositis
2020 National Ryan White Conference on HIV Care & Treatment
Increasing Uptake of PrEP in Cis-Women Through a Health Educator-Driven Walk-In Sexual Health Clinic
Mary's Center
David Cornell, Ashlee Wimberly
2020 National Ryan White Conference on HIV Care & Treatment
AIDS Care Group
2020 National Ryan White Conference on HIV Care & Treatment
Our Lady of the Lake, Inc.
2020 National Ryan White Conference on HIV Care & Treatment