Collection of implementation guides on evidence-informed best practices in HIV care delivery.
Interdisciplinary Teams
Involvement of staff from a range of professions is utilized by some HIV care agencies so that varied client issues can be addressed within the context of a single agency’s care team. Disciplines may include not only HIV clinical care but also opioid treatment, population-specific care expertise, and other areas of experience.
Best Practices
- Center for Innovation and Engagement
- Boston University School of Social Work Center for Innovation in Social Work and HealthResources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model.
- 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.
- 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.
- Center for Innovation and EngagementTeam that provides comprehensive culturally and linguistically appropriate HIV primary care and services to Hispanic/Latino people with HIV who speak Spanish as their primary language.
- Best Practices CompilationThe Bottom-Up Project is a multi-organizational initiative focused on leveraging health information exchange data and peer navigation. Using real-time clinical data, in combination with linkage to HIV care and social services, the Bottom-Up Project locates and reengages people with HIV who are not currently in medical care and are not virally suppressed. Through this collaboration, over half of patients on the lost-to-follow-up list were found and invited to enroll in the linkage to care/reengagement program.
- Best Practices CompilationThis medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.
- 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 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 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 HIV clinic at Washington University integrated comprehensive hepatitis C virus (HCV) screening and treatment into its care model. Chronic HCV is a “silent” infection as it damages the liver over time, often without symptoms. Early treatment of HCV is particularly important among people with HIV, as HIV accelerates HCV’s progression. Of the 1,711 clients served at the clinic each year, 174 had a detectable HCV viral load. These clients received integrated clinical and support services to reduce barriers to ongoing HCV care engagement.
- 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 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.
- Center for Innovation and EngagementLink-Up Rx is a data to care (D2C) program that aims to increase retention in care and viral suppression among people with HIV by using prescription refill information to decrease the length of time between refills and reduce antiretroviral therapy (ART) interruption.
- 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 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 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 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 CompilationMacGregor 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.
Documents
- SPNS Sexually Transmitted Infections InitiativeTools to help clinics improve screening, testing, and treatment of common bacterial STIs among people with HIV or at risk for HIV.
- 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)
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).
- 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
Yale University School of Medicine
Anthony Eller, Kimberly Johnson, Elizabeth DiDomizio, Lynn Madden, Jennifer Olivia, Frederick Altice
2022 National Ryan White Conference on HIV Care & Treatment
Oregon Health Authority
Heather Hargraves, Sara Pyle, Jeffrey Williams
2022 National Ryan White Conference on HIV Care & Treatment
Open Health Care Clinic
Jamie Roques, William Spatafora
2020 National Ryan White Conference on HIV Care & Treatment
El Rio Health
Sharon Dipasupil
2020 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