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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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HOME: Homeless Health Outreach Mobile Engagement
HHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.Resource updated 02/12/2024
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KC Life 360: Employment-Focused Intervention to Link Clients to Support Services and Housing
KC Life 360 is an employment-focused intervention that utilizes the intersection between employment services, HIV care and treatment, and housing to improve health outcomes of people with HIV.Resource updated 10/13/2023
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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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TransActivate
Bienestar developed TransActivate to improve timely engagement and retention in HIV care among Latina transgender women. Linkage coordinators/peer navigators use a strengths-based approach to help clients reach their goals of entering and staying in medical care to ultimately reach viral suppression.Resource from the RWHAP Best Practices Compilation updated on 02/12/2024
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Innovative HIV Care Strategies to Support Individuals Who Are Unstably Housed
Two interventions (KC Life 360 and HHOME) that provide layers of supportive services for people with HIV who are unstably housed.Resource updated 05/15/2024
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Healthy Divas: E2i
Healthy 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.Resource from the RWHAP Best Practices Compilation updated on 04/18/2024
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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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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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SURE Housing Initiative
SPNS initiative on development of housing-related intervention strategies for three populations with HIV experiencing unstable housing: LGBTQ+; people ages 13-24); and people who have been justice involved. Project period: 2022-2025.RWHAP Technical Assistance Provider updated on 06/24/2024
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The Time is Now: Implementing Innovative Housing Model for People with HIV to Improve Health Outcomes
Review of a SPNS data integration project that opened the door for innovating how people with HIV are being prioritized through the new HUD housing prioritization mandates.
Resource (Conference Presentation) updated 09/14/2023
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Improving Reengagement in Care Using a Community Health Worker Model: Evidence from New Orleans
Lessons learned from an EMA-wide effort to embed community health workers in RWHAP Part A agencies to improve retention in care.
Resource (Conference Presentation) updated 09/14/2023
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Operation BRAVE: Ending the Epidemic by Achieving Health Equity through Patient Navigation
Review of a patient navigation model and its three components.
Resource (Conference Presentation) updated 09/14/2023
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Empowerment through Health Education and Peer Support: Vivir Inspirar Defender Amar
Ideas for how to replicate a conference, developed by and for people with HIV, can create a safe space to address the ongoing needs of the community at large.
Resource (Conference Presentation) updated 09/14/2023
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Long-Term Survivors Support Group
This 12-week pilot program focused on addressing the needs of long-term survivors.
Resource (Conference Presentation) updated 09/14/2023
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Housing, Employment, and HIT Improve Access for Vulnerable Populations in Paterson, New Jersey, and Puerto Rico
Discussion of a holistic process and a health information technology solutions-based approach for increasing access to housing and employment services for vulnerable populations, including people with a history of incarceration.
Resource (Conference Presentation) updated 09/14/2023
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Improving HIV Health Outcomes through Coordinated HIV Care, Housing, and Employment Services
Results of a study demonstrating the impact that coordinated care, housing, and employment can have on the HIV health outcomes of unstably housed and under/unemployed people with HIV.
Resource (Conference Presentation) updated 09/14/2023
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HIV Outbreak in West Virginia: The Importance of Collaboration and Partnerships
Discussion of diverse partnerships developed to successfully treat a homeless population with addiction and newly diagnosed HIV as well as the service delivery challenges faced by an out-of-state Part C clinic.
Resource (Conference Presentation) updated 09/14/2023
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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