To 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.
Part A - Hard Hit Urban Areas
Ryan White Part A funds HIV/AIDS care in metropolitan areas hardest hit by the epidemic. Medical and support services for underserved individuals are put into place through a sequence of activities. First is planning, which sets the framework for funding decisions. Next, Part A recipients (local governments) advertise for and award contracts to service agencies. Care is then delivered by funded agencies, which follow Ryan White standards that cover areas like quality of care and data reporting. Part A recipients monitor and manage grant funds to ensure services are delivered according to standards. Learn more about Part A, formula and supplementary grants, eligible services, and more.
- RWHAP programs can contact HRSA project officers and technical assistance and training partners for support.
- Use the Services Locator to find a RWHAP recipient, subrecipient, or Planning Council.
- See Planning and Part A - Planning Councils topic pages.
Best Practices
- Best Practices Compilation
- Best Practices CompilationHispanic and Latino clients served by the team received culturally responsive care and linkages to external community resources, with resulting greater retention in care and improved viral suppression rates.
- 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 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 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 CompilationThis 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.
- 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 CompilationGolden Compass aims to serve the unique needs of older adults with HIV using a comprehensive care model designed to address comorbidities that arise with older age. Golden Compass helps address the large, yet preventable, gaps in knowledge about geriatric HIV care, resulting in high rates of patient and provider satisfaction and substantial provider reach.
- Best Practices CompilationThe Huntridge Family Clinic launched the Rapid Start Initiative to provide same-day ART treatment and comprehensive case management to clients with a new diagnosis of HIV. Over 90% of clients received ART on the same day as diagnosis, and 78% of clients were retained in care within the first year of starting treatment.
- Best Practices CompilationIn 2021, the City of New Orleans employed five CHWs to work with RWHAP Part A-funded agencies on reengaging eligible clients back into care. From February 2021 through April 2022, CHWs attempted to contact 1,215 clients disconnected from care; 207 of these attended a primary care appointment and re-entered care, a 17% success rate at reengaging clients back into care.
- Best Practices CompilationA broad population of men who have sex with men (MSM) reached viral suppression through intensive case management by applying tools and lessons learned in the Center for Quality Improvement Innovation end+disparities ECHO Collaborative.
- 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 CompilationThis referral-based oral health model used dental navigators to connect clients to a large network of dentists, which facilitated scheduling of appointments.
- Best Practices CompilationExpanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
- Best Practices CompilationThis data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.
- 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 CompilationThe New York City HIV Care Coordination Program is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. Multiple evaluations of the program consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.
- Best Practices CompilationPositive 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 CompilationPositiveLinks is a mobile platform deployed by clinics or community-based organizations to connect people with HIV to a digital support community. The client-facing app helps people with a new diagnosis of HIV become engaged in care and helps people at risk of being lost to care overcome barriers related to geographic or social isolation. From the app, people can access Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant patient dashboards, secure messaging, and patient lab records. People who used PositiveLinks had increased rates of retention in care and viral suppression.
- Best Practices CompilationProject 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 CompilationThe Maricopa Jail Project was implemented by five jails to decrease the wait time between incarceration and/or diagnosis to the start of treatment, and to better support clients to reach viral suppression. Maricopa hired a nurse practitioner to manage access and case manage across the jail system. The initiative was successful in increasing the number of clients who were virally suppressed.
- Best Practices CompilationRoutine 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 CompilationThrough the Test & Treat Rapid Access (TTRA) Program, clients with a new HIV diagnosis in Miami-Dade County can access ART, receive other services and counseling, start enrolling in RWHAP, and connect to HIV primary care during the initial visit. At Borinquen Health Care Center, one of the clinical sites participating in TTRA, 76% of clients were virally suppressed within three months of receiving a rapid ART start, and 95% were retained in care for 12 months.
- Best Practices CompilationThe Max Clinic, located within the University of Washington’s Harborview Medical Center complex in Seattle, offers walk-in services and incentives to clients reengaging in HIV care, especially those who have not been well served by the traditional health care model—including clients who are experiencing homelessness, or who have mental health and substance use issues. The Max Clinic offers rapid antiretroviral therapy, incentives, a flexible clinical model, and access to comprehensive support services. Max Clinic clients were significantly more likely to reach viral suppression after 12 months than a comparable control group.
- Best Practices CompilationThe 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 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.
Resources
- Ryan White Data SupportInstructions on how RWHAP Part A recipients can access, complete, and submit the RWHAP Part A Expenditures Report.
- HRSA HIV/AIDS Bureau (HAB)
Series of manuals for Parts (programs) under HRSA's Ryan White HIV/AIDS Program (RWHAP).
- 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), Centers for Disease Control and Prevention (CDC)This guidance outlines the planning requirements for Ryan White HIV/AIDS Program (RWHAP) Parts A and B recipients and all DHAP-funded state and local health departments.
- HRSA HIV/AIDS Bureau (HAB)
Performance measures to help Ryan White HIV/AIDS Program agencies monitor and improve the quality of care they deliver.
- Ryan White Data SupportInstructions on how RWHAP Part A recipients on the RWHAP Part A PTR.
- Data Integration, Systems and Quality (DISQ) Team, Ryan White Data SupportInstructions on how all EHE recipients can access, complete, and submit the EHE Allocations Report.
- Ryan White Data SupportInstructions on how all EHE recipients can access, complete, and submit the EHE Expenditures Report.
- EHE Systems Coordination ProviderList of local and state EHE points of contact.
- HRSA HIV/AIDS Bureau (HAB)
Update to the Unmet Need Methodology for RWHAP Part A and B recipients.
- Indianapolis TGA
Tools used for quality and program monitoring by a Part A program.
- Cleveland/Lorain/Elyria TGA
Tools developed by a Part A program to monitor programs and services.
Tools developed by a Part A program to monitor services and program administration.
- New Haven EMA
Tools for site visits and program monitoring developed by a Part A program.
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).
- HRSA HIV/AIDS Bureau (HAB)Resources for RWHAP recipients on administering their grants, including reverse site visit materials.
- HRSA HIV/AIDS Bureau (HAB)
Webinars and other special events by HRSA's HIV/AIDS Bureau.
- HRSA HIV/AIDS Bureau (HAB)his HRSA HIV/AIDS Bureau pre-application webinar for the RWHAP Part A HIV Emergency Relief Grant Program (HRSA-25-054).
- HRSA HIV/AIDS Bureau (HAB)HRSA HIV/AIDS Bureau DMHAP stakeholder calls with the RWHAP Part A and EHE Initiative stakeholder community at large.
Conference Presentations
HRSA HIV/AIDS Bureau, Division of Metropolitan HIV/AIDS Programs
2022 National Ryan White Conference on HIV Care & Treatment
HRSA HIV/AIDS Bureau, Division of Metropolitan HIV/AIDS Programs
Chrissy Abrahms Woodland, Monique G. Hitch
2022 National Ryan White Conference on HIV Care & Treatment
AIDS Foundation Chicago
Anthony Guerrero, Jill Dispenza, Carmen Corredor
2022 National Ryan White Conference on HIV Care & Treatment
HRSA HIV/AIDS Bureau
Division Staff
2020 National Ryan White Conference on HIV Care & Treatment
Massachusetts Department of Public Health
Dennis Canty, Randie Kutzen, Alyssa Harrington
2020 National Ryan White Conference on HIV Care & Treatment