Part C - Community-Based Early Intervention

Part C of HRSA's Ryan White HIV/AIDS Program (RWHAP) provides comprehensive primary health care in an outpatient setting for people living with HIV disease. The main Part C program, Early Intervention Services (EIS), funds hundreds of community agencies to engage underserved individuals in HIV/AIDS care. A smaller Part C program, called Capacity Development, funds agencies to build or improve their ability to deliver HIV/AIDS care.

Questions about Part C Capacity Development? Email [email protected].

Best Practices

  • Best Practices Compilation
    Ten 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 Compilation
    Lehigh Valley Health Network Comprehensive Health Services implemented a trauma-informed approach to care delivery, including training staff on how trauma can affect people’s health and how microaggressions in healthcare environments can potentially trigger trauma responses. This approach positively impacted care delivery and the program’s retention in care rate.
  • Best Practices Compilation
    The goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
  • Best Practices Compilation
    By 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 Compilation
    The 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 Compilation
    The University of Pittsburgh Medical Center, Center for Care of Infectious Diseases, Pittsburgh Area Center for Treatment (PACT) began implementing the Food Assistance Program in August 2017 to serve as a supplemental resource for people with HIV receiving care who experience food insecurity. The program helps bridge gaps in Supplemental Nutrition Assistance Program (SNAP) benefits and monthly food costs while promoting access to healthy foods and retention in HIV care.
  • Best Practices Compilation
    Allegheny Health Network implemented Patient-Centered Appointment Reminders over a five-month period to improve engagement in care for people with HIV. This intervention included text message reminders, a process for identifying and addressing barriers to care, home visits, and outreach to patients after missed appointments. Compared to the pre-intervention cohort, the post-intervention group showed a significant decrease in clinic no-show rates.
  • Best Practices Compilation
    Positive Care Center implemented the Rapid Access program in 2018, providing clients with ART on the same day as HIV diagnosis. Pharmacists, embedded within Positive Care Center’s care team, help clients with their treatment plans and adherence strategies. Over 90% of clients served through Rapid Access in 2021 received ART on the same day as diagnosis, and 82% of clients were retained in care at six months.
  • Best Practices Compilation
    Project ACCEPT is designed to improve engagement and retention in medical care for youth ages 16 to 24 years with newly diagnosed HIV. The educational and skill-building intervention was deployed at four demonstration sites and increased rates of medication use and appointment adherence in comparison to a control group. Although originally developed for cisgender youth, Project ACCEPT may be adapted for gender-diverse people.
  • Best Practices Compilation
    The 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 Compilation
    Southeast Mississippi Rural Health Initiative, Inc., a network of community health centers serving Southern Mississippi, uses data-driven quality improvement techniques to identify youth who are not virally suppressed or have missed appointments. Medical case managers use a client checklist to identify and address barriers to antiretroviral therapy (ART) and medical care adherence. They also use a health literacy visual illustration tool to help youth understand the effects of ART on viral suppression. The intervention strategy was successful in improving viral suppression rates for youth.
  • Best Practices Compilation
    Routine Universal Screening for HIV (RUSH) provides non-medical case management services, opt-out HIV testing, and linkage to care for emergency department patients. The intervention automatically screens patients for HIV if they are aged 16 years or older, are having an IV inserted, or are having blood drawn for other reasons, unless the patient opts out. RUSH provides access to testing earlier in disease progression, bridging disparities that primarily impact people of color. It also promotes linkage to and retention in care for those with a positive HIV test result. Clients with a positive HIV test in the emergency department who had a prior diagnosis of HIV were more likely to be retained in care and to reach viral suppression.
  • Best Practices Compilation
    The University of Nebraska Medical Center/Nebraska Medicine (UNMC/NM) Specialty Care Center (SCC) is the largest provider of comprehensive HIV care—including primary and HIV-focused medical services as well as multiple support services—in Nebraska. In March 2020, at the onset of the COVID-19 pandemic, the clinic integrated telehealth into its care delivery model to continue serving patients beyond the clinic structure, and developed algorithms that allowed any team member to quickly identify a patient's eligibility for a telehealth visit. The algorithms include the date of the most recent office visit, stability of HIV disease, most recent viral load and CD4 count, and antiretroviral therapy (ART) refill histories as a proxy for medication adherence. Overall, viral suppression rates remained high for all patients regardless of visit type, indicating that telehealth is a successful alternative to in-person visits for providing HIV care.
  • Best Practices Compilation
    The Test and Treat initiative, implemented by Oklahoma State University, connects people to antiretroviral therapy (ART) within 14 days of HIV diagnosis through streamlined intake and initial clinic visit protocols and 30-day medication starter packs. Participants in Test and Treat are linked to care and reach viral suppression sooner, and are more likely to be retained in care, as compared with people in standard care.
  • Best Practices Compilation
    The Rutgers New Jersey Medical School created a transgender health program and integrated it into their Infectious Disease Practice. The program conducted community outreach to engage transgender men and women in care, trained all staff on gender affirming care, hired transgender staff, provided gender affirming care and hormone treatments onsite, and offered mental health support to patients.
  • Best Practices Compilation
    MacGregor 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.

Resources

  • HRSA HIV/AIDS Bureau (HAB)

    Federal agency that administers the Ryan White HIV/AIDS Program (RWHAP), which helps low-income people with HIV receive care.

  • HRSA HIV/AIDS Bureau (HAB)

    Performance measures to help Ryan White HIV/AIDS Program agencies monitor and improve the quality of care they deliver.

  • RWHAP Data Support

    Instructions on how all Ryan White HIV/AIDS Program (RWHAP) Part C recipients can access, complete, and submit the RWHAP Part C Allocations Report.

  • RWHAP Data Support, Ryan White Data Support
    The RWHAP Part C Expenditures Report.
  • Ryan White Data Support
    Instructions on how all EHE recipients can access, complete, and submit the EHE Allocations Report.
  • Ryan White Data Support
    Instructions on how all EHE recipients can access, complete, and submit the EHE Expenditures Report.

Webinars

Conference Presentations

HRSA HAB DCHAP, Alaska Native Tribal Health Consortium, JWCH Institute, Inc.
Laurali Riley, Harold Glenn San Agustin
2022 National Ryan White Conference on HIV Care & Treatment
HRSA HAB Division of Community HIV/AIDS Programs (DCHAP)
CAPT Mahyar Mofidi, DMD, PhD; Stephanie Yun, MPH, CHES; and others
2022 National Ryan White Conference on HIV Care & Treatment
HRSA
Gail Kelly, Mindy Golatt, Catisha Mosley
2022 National Ryan White Conference on HIV Care & Treatment
Massachusetts Department of Public Health
Sandra Broughton, Jane Fox
2020 National Ryan White Conference on HIV Care & Treatment
AIDS Alliance for Women, Infants, Children, Youth & Families
2020 National Ryan White Conference on HIV Care & Treatment

Technical Assistance

Upcoming Events