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SPNS Initiative: SURE Housing Initiative (2022-2026)
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Collaborative Care Management: E2i
Collaborative 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.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Integration of HCV Treatment within an HIV Clinic
The 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.Resource from the RWHAP Best Practices Compilation updated on 05/15/2024
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Pay it Forward Transitional Care Coordination
One 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.Resource from the RWHAP Best Practices Compilation updated on 05/07/2024
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Beyond the Walls: Building Foundation for Jail Linkage Programs
Effective models and best practices for connection to care for justice-involved individuals.Resource updated 05/15/2024
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Transitional Care Coordination: From Jail Intake to Community HIV Care Intervention
Transitional Care Coordination (TCC) connects people with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails.Resource from the RWHAP Best Practices Compilation updated on 02/02/2024
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Community Health Workers: Improving Linkage and Retention in HIV Care
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.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Link-up Rx
Link-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.Resource updated 09/14/2023
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Maricopa County: Expanding Jail Services & Improving Health for Incarcerated People with HIV
The 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.Resource updated 10/13/2023
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LINK LA
LINK 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.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Maricopa County Jail Project: Providing HIV Service to People Who Are Incarcerated
Partnership between jail staff and public health prevention staff created new data communication systems and bundled services for clients upon release.Resource updated 05/15/2024
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Patient-Centered HIV Care Model
The 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.Resource from the RWHAP Best Practices Compilation updated on 11/26/2023
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Cultivating Growth: Home-based Behavioral Health and Supportive Housing across Oregon's Balance of State
Review of the Oregon model of integrating intensive case management, behavioral health, in-home and other wrap-around services with housing assistance and its replication potential in other jurisdictions.
Resource (Conference Presentation) updated 09/14/2023
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Homeless Health Outreach Mobile Engagement (HHOME)
HHOME 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.Resource from the RWHAP Best Practices Compilation updated on 11/27/2023
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Navigator Case Management for People Leaving Jail
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.Resource from the RWHAP Best Practices Compilation updated on 01/19/2024
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Enhanced Patient Navigation for Women of Color
The 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.Resource from the RWHAP Best Practices Compilation updated on 02/28/2024
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Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations
The RWHAP Part F SPNS program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.Resource from the RWHAP Best Practices Compilation updated on 11/13/2023
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MORE: Mobile Outreach Prevention and Engagement
MORE 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.Resource from the RWHAP Best Practices Compilation updated on 04/15/2024
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Telemedicine to Achieve HIV Viral Suppression in Incarcerated People in Tennessee – 9-year retrospective (2010 – 2018)
In collaboration with Tennessee Department of Corrections, we developed and implemented a stepwise HIV telemedicine program to optimize viral suppression in the state prisons during 2010-2018. Clinic attendance increased from 50 percent to 90 percent during full implementation. Viral suppression increased from 30 percent in 2010 to 90 percent in 2018.
Resource (Conference Presentation) updated 09/14/2023