Evidence-informed HIV care interventions (jail transitional care, buprenorphine, patient navigation, peer support for women of color).
Linkage services are critical to helping people living with HIV find and stay in care. For newly diagnosed people, rapid (same day) linkage is becoming a standard. Patients undergoing life transitions (moving, loss of insurance, release from jail or prison) need linkage services that are sensitive to their situations.
- Dissemination of Evidence Informed-Interventions Project (DEII)
- IHIPIntervention featuring time-limited services and outreach to help identify, treat, and prevent HIV and STIs.
- Best Practices CompilationHoward Brown Health, is a Chicago-based Federally Qualified Health Center that provides clinical and supportive services focused on meeting the needs of the LGBTQ+ communities, including people with HIV. Howard Brown Health established a specialized drop-in clinic and support groups, and implemented organizational initiatives to provide culturally relevant and gender-affirming services for transgender and non-binary people, including transgender women of color. The goal of this intervention was to optimize engagement and retention in HIV services and primary care. From 2012-2016, the number of transgender and non-binary people served in primary care at Howard Brown Health more than tripled.
- 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.
- 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.
- 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 CompilationThe CrescentCare Start Initiative is a program of CrescentCare, a Federally Qualified Health Center, and the New Orleans Office of Health Policy. The initiative connects people with newly diagnosed HIV to antiretroviral therapy (ART) through intensive patient navigation and a streamlined intake process. Time between HIV diagnosis and linkage to HIV medical care has decreased from 30 days to only 1.3 days.
- Best Practices CompilationThe Oregon Health Authority awarded contracts to local public health authorities across the state to work with community partners to integrate early intervention services and outreach services, link people to HIV care, and provide support to help clients reach viral suppression. Quick linkage to care resulted in a median of 57 days to viral suppression for Early Intervention Services and Outreach clients in 2019.
- Center for Innovation and EngagementIntervention to re-engage people with HIV to care by utilizing a real-time data exchange system that connects clients with health department linkage specialists when presenting to the emergency department.
- 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 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 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 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.
- Center for Innovation and Engagement
- Best Practices CompilationThe Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.
- Best Practices CompilationThe Navigator Case Management intervention helps people with HIV who are incarcerated and are leaving to return to the community. The intervention uses harm reduction, case management, and motivational interviewing techniques to promote healthy behaviors. Enhanced case management including peer support and connection to other needed services both immediately before and after release supports increased linkage to and retention in HIV care for people transitioning to the community from jail.
- 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 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.
- Center for Innovation and EngagementClinic-based mobile health intervention that promotes linkage to and engagement in HIV care in rural areas for people with HIV who are new to care or at risk of falling out of care.
- 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.
- Center for Innovation and Engagement
- University of Washington
Online clinician training platform with evidence-based core competency training on HIV prevention, screening, diagnosis, care, and key populations.
- IHIPUse of a transnational framework to provide intensive services, including one-on-one educational sessions, to help Latino men and Latina transgender women link to and stay engaged in care and treatment.
Lessons learned from the SPNS initiative Enhancing Linkages to HIV Primary Care & Services in Jail Settings.
- 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.
- Dissemination of Evidence Informed-Interventions Project (DEII)
Preliminary data and lessons learned from the pre-implementation and early-implementation phases of initiatives featured in the DEII project (buprenorphine, women of color, peer support, jail transitional care).