EHE Innovations and Best Practices

Alabama

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 14,436 PLWH or 340 people/100k

Arkansas Department of Health (Arkansas)

• Name of Program: Positive Miles
• EHE Pillar: Treat
• Type of Intervention:Retention, Viral Suppression
• HIV incidence/prevalence from AIDSVu: 6,225 PLWH or 246 people/100k
• PDF of Program Summary Report

The Positive Miles program aims to alleviate transportation barriers that would prevent a client from being engaged in HIV medical services and treatment. The program provides safe and easily accessible transportation services that provide clients peace of mind, knowing they will get to their medical appointments and other supportive services as needed.

DC Health (Washington, DC)

• Name of Program: Harm Reduction Vending Machines
• EHE Pillar: Prevent
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Youth, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: N/A
• PDF of Program Summary Report

The goal of the program is to decrease the prevalence of HIV/AIDS and overdoses within the District, it is important that DC Health addresses the various modes that the disease can be transmitted. This includes, but is not limited to, unsafe sexual practices and needle sharing. The harm reduction products (i.e., condoms, Narcan, and fentanyl test strips, etc.,) within the Harm Reduction Vending Machines directly address this need. DC Health awarded sub-grants to two community partners, Family and Medical Counseling Service, Inc., (FMCS) and Honoring Individual Power and Strength (HIPS), to pilot the implementation of Harm Reduction Vending Machines in Washington, DC. These machines have become prevalent in multiple cities to provide low-barrier access to the most vulnerable populations. The machines were deployed to distribute an array of self-care products ranging from hygiene and wellness kits to lifesaving tools for opioid overdose prevention (Narcan). The Department of Behavioral Health (DBH) provides prevention, intervention and treatment services and supports for children, youth and adults with mental and/or substance use disorders including emergency psychiatric care and community-based outpatient and residential services. DBH supplies Narcan and fentanyl test strips for the HRVMs. The mission of the District of Columbia Fire and Emergency Medical Service Department (FEMS) is to preserve life and promote health and safety through excellent pre-hospital treatment and transportation, fire prevention, fire suppression and rescue activities and homeland security awareness. FEMS hosts four (4) HRVMs at various sites.

Kentucky

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 8,137 PLWH or 215 people/100k

Missouri Department of Health and Senior Services (Missouri)

• Name of Program: EHE Services
• EHE Pillar: Treat
• Type of Intervention: Community Engagement, Performance Measures, Medication Access, Stigma Reduction, Re-Engagement, Data to Care, Social Media, Outreach
• Target Population: All - PWID, Black/African American, Transgender/Nonbinary, Spanish speakers, Aging Population, Hispanic/Latinx, Women, Youth, PLWH, MSM, Other
• HIV incidence/prevalence from AIDSVu: 13,103 PLWH or 252 people/100k
• PDF of Program Summary Report

The income eligibility threshold in Missouri for Ryan White services and supports is 300 percent of the FPL. We know that Missourians living with HIV continue to struggle to afford their HIV care above the income. EHE Services provides financial assistance to PLWH who do not qualify or decline the Ryan White program services. Using a data-to-care model, the Office of Epidemiology provides a list of people not engaged in HIV medical care for the previous 13-36 months to the EHE Coordinators in a REDCap instance. Additionally, PLWH previously enrolled in Ryan White who were ended in Ryan White case management less than 24 months ago are referred to the respective case management agency for location and re-engagement in HIV medical care within thirty days after being determined out of care. PLWH are supported to re-engage in HIV medical care through their first medical appointment to viral suppression using either the Ryan White program and services or EHE services. The anticipated measurable outcomes when the program is fully operational are: improved viral suppression rates for all Missourians living with HIV, improved retention in HIV medical care, and better linkage to care numbers.

Mississippi

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 9,873 PLWH or 400 people/100k

Oklahoma

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 6,948 PLWH or 210 people/100k

South Carolina Department of Public Health (South Carolina)

• Name of Program: Home Testing Program
• EHE Pillar: Respond
• Type of Intervention: Self-Testing
• Target Population: All - PWID, Black/African American, Transgender/Nonbinary, Spanish speakers, Aging Population, Hispanic/Latinx, Women, Youth, PLWH, MSM, Other
• HIV incidence/prevalence from AIDSVu: 18,109 PLWH or 411 people/100k
• PDF of Program Summary Report

Sixteen percent of people living with HIV in South Carolina do not know their HIV status and are therefore not taking advantage of available HIV treatment and care services. Barriers to HIV testing include stigma, lack of transportation, poverty, and lack of access to healthcare. The goal of the Home Testing Program (HTP) is to increase early HIV diagnosis by making testing more accessible through home test kits, ultimately contributing to the national goal of reducing new HIV infections by 75% by 2025 and 90% by 2030. The program also aims to improve health outcomes by ensuring that individuals who test positive for HIV can promptly begin care and treatment, reducing the risk of transmission to others and supporting the broader effort to end the HIV epidemic.ome of the program's measurable outcome are:
1. increased HIV testing uptake, compared to baseline testing rates before the program's implementation.
2. The program's ability to reach underserved or high-risk populations across all 48 counties in South Carolina, ensuring widespread access to HIV testing.
3. Participant engagement is also a measurable outcome where the program tracks the high completion rates of both pre-test and post-test surveys, indicating strong participant engagement and the program's ability to collect data.

San Juan Municipio

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 3,662 PLWH or 1,212 people/100k

Maricopa County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 12,402 PLWH or 329 people/100k

County of Los Angeles Department of Public Health, Division of HIV and STD Programs (DHSP) (Los Angeles County, CA)

• Name of Program: Innovation Awards and Mini-Grants
• EHE Pillar: Prevent/Diagnose/Treat
• Type of Intervention: Diagnosis, Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Youth, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 50,466 PLWH or 602 people/100k
• PDF of Program Summary Report

As part of the Ending the HIV Epidemic (EHE) Initiative, the Los Angeles County Department of Public Health (LAC Public Health), Division of HIV and STD Programs (DHSP) resolved to support new partnerships and innovative projects to help meet EHE goals through a Mini-Grant and Innovation Award program. The one-year program includes a total of 25 interventions implemented throughout the County, including but not limited to: art-based workshops, a 24-hour hotline to connect community members to an infectious disease provider, HIV and syphilis co-infection simulation modeling, transgender, gender-nonconforming, and intersex (TGI) EHE ambassadors, promoting health in the House and Ball community, and more. The goal of the program is to implement innovative interventions to prevent the transmission of HIV, diagnose HIV as quickly as possible, and/or improve health and quality of life of those with HIV or indirectly impacted by it. The Innovation Awards provides awarded agencies up to $250,000 per year for more complex projects while the Mini-Grants are smaller in scope and provide up to $50,000 per year.

County of Los Angeles Department of Public Health, Division of HIV and STD Programs (DHSP) (Los Angeles County, CA)

• Name of Program: Data for Adherence, Retention, and Engagement to Care (DARE2Care)
• EHE Pillar: Respond
• Type of Intervention: Linkage, Retention
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Women, Transgender/Nonbinary, People who inject drugs, Other
• HIV incidence/prevalence from AIDSVu: 50,466 PLWH or 602 people/100k
• PDF of Program Summary Report

DARE2Care utilizes data to care as a strategy for clinics to address gaps in essential HIV care access by identifying individuals living with HIV who have (1) fallen out of HIV care, (2) are at risk of falling out of care, (3) or who have never engaged in care by conducting outreach and linking them to HIV treatment.. Building the capacity of the clinics to independently examine their data collection and analysis processes can strengthen their identification of individuals not in care and reduce the number of individuals lost to follow-up care. DARE2Care aims to enhance the capacity of local HIV care providers to employ a data to care approach in identifying, outreaching to, and re-engaging people with HIV (PWH) who are not currently in care. Additionally, DARE2Care seeks to strengthen clinic capacity to closely monitor electronic medical records and patient data to deliver intensive case management, ultimately increasing the number of PWH in care and achieving undetectable viral loads. ""DARE2Care’s operational strategy is grounded in the data to care approach (a key focus areas of the EHE Respond Pillar) that utilizes data to drive program planning. DARE2Care’s strategy consists of multiple key activities and components focusing on data and patient outreach activities. A key activity is hiring a Data Analyst, to ensure data is effectively managed, analyzed, and interpreted in real time to identify priority populations, gaps in care, and areas requiring targeted interventions. In DARE2Care, the Data Analysts are essential to building a data system that collects and maintains out-of-care client data from various sources such as electronic health records, laboratory reports, and prescription pick-up information. In addition, DHSP’s Surveillance Unit provides updated location information and verifies care status utilizing internal surveillance information.

LA County Department of Public Health Division of HIV and STD Programs (Los Angeles County, CA)

• Name of Program: iCARE
• EHE Pillar: Treat
• Type of Intervention: Viral Suppression
• Target Population: PLWH, Youth
• HIV incidence/prevalence from AIDSVu: 50,466 PLWH or 602 people/100k
• PDF of Program Summary Report

The Incentives for Care, Adherence, Retention and Engagement (iCARE) Program aims to address gaps in viral suppression rates among people with HIV (PWH) in Los Angeles County (LAC), particularly among adults ages 18-29 and adults who are virally unsuppressed, by implementing conditional financial incentives for improved HIV outcomes. Despite evidence of the effectiveness of such incentives, there remains a lack of knowledge on their practical application in real-world settings and at the health department level. The goal of the iCARE program is to improve HIV outcomes among young adults and people who are virally unsuppressed with HIV in Los Angeles County using conditional financial incentives for demonstrating viral suppressions and regular client engagement via two-way text messaging. The program aims to support clients in reaching viral suppression, increase the percentage of participants with a suppressed viral load and sustained viral load suppression, while also assessing the acceptability, feasibility, and satisfaction of the program among participants and staff.

New Orleans Parish

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,860 PLWH or 1,503 people/100k

San Francisco County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 11,620 PLWH or 1,590 people/100k

East Baton Rouge Parish

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,127 PLWH or 1,088 people/100k

Columbus Public Health (Franklin County, OH)

• Name of Program: Status Neutral Housing Program - HOME (Housing, Outreach, Motivation, and Engagement)
• EHE Pillar: Prevent/Treat
• Type of Intervention: Retention, Viral Suppression
• Target Population: MSM, Black/African American, PLWH, Hispanic/Latinx, Transgender/Nonbinary
• HIV incidence/prevalence from AIDSVu: 5,256 PLWH or 479 people/100k
• PDF of Program Summary Report

The purpose of this service is to provide emergency financial assistance to prevent homelessness, and/or establish permanent housing for people living with HIV as well as individuals who are at an increased risk of HIV. Using a housing first model, the goal is for clients to maintain viral suppression or to stay HIV-negative. Program funds may be used for costs listed as allowable under PCN 16-02 for the housing service category. The majority of clients receive financial support for rent payments and utilities. The subrecipient is exploring other ways to increase the number of landlords who accept third-party payments in order to better serve clients and to offer other housing options that may not have been available before. While this is a housing-first model, clients enrolled have access to services including but not limited to assessment and care coordination. Care coordinators on staff provide linkage to case management, addiction services, primary health care, HIV treatment, PrEP, and partner agencies who provide community-based access to stabilizing resources, such as housing, transportation, employment, legal aid, government benefits, ID cards and more. With the program still in the pilot phase, there are no outcomes to share, but we will be monitoring over the next year.

Cuyahoga County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,971 PLWH or 466 people/100k

San Diego County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 13,524 PLWH or 485 people/100k

Alameda County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 5,986 PLWH or 424 people/100k

Wayne State Horizons Project EHE THRIVE (Wayne County, MI)

• Name of Program:Wayne State Horizons Project EHE Thrive Support Group
• EHE Pillar: Treat
• Type of Intervention: Retention, Viral Suppression
• Target Population: Black/African American, Youth, Aging Population, PLWH, Other
• HIV incidence/prevalence from AIDSVu: 7,235 PLWH or 490 people/100k
• PDF of Program Summary Report

Young adults living with HIV since birth (perinatal PLWH) experience worse health outcomes due to multiple factors including poorer adherence, medication resistance, shame, stigma, anger, and aversion to treatment. Perinatal youth have repeatedly expressed “we are different” and “we need our own support group” due to their unique life experiences and situations. The group was developed in response to demand from our adult perinatal population, and it was named “Thrive” to honor the fact that this population has survived and thrived their whole lives. The overall goal of the group is to address the social determinants that impede these individuals living with HIV since birth from participating in care and/or being adherence to retroviral therapy including shame, anger, and aversion to treatment. The Horizons Project THRIVE support group is under the supervision of Jill Meade PhD and Ayanna Walters, RN, BSN, with assistance from Charnell Cromer, RN. It meets twice monthly to discuss topics selected by the client group and the moderators. The group provides a safe haven for this population to connect (and re-connect) with others who have lived this unique life experience.

Community Health Awareness Group (Wayne County, MI)

• Name of Program: Project H.O.M.E. (Housing Opportunity Mobilzation Expereince)
• EHE Pillar: Treat
• Type of Intervention: Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 7,235 PLWH or 490 people/100k
• PDF of Program Summary Report

Project H.O.M.E. is designed using the Housing First Model. The program seeks to assist clients in accessing and maintaining housing through education and skills building. The goal of the program is to assist clients in accessing and maintaining housing. The program provides Housing Summits to clients and housing providers to assist clients in successfully obtaining and maintaining housing through education, assists clients in finding affordable housing, provides support through the housing selection process, and assists with any issues that arise.

Community Health Awareness Group (Wayne County, MI)

• Name of Program:Healthy U
• EHE Pillar: Treat
• Type of Intervention:Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 7,235 PLWH or 490 people/100k
• PDF of Program Summary Report

Project Healthy “U” (U= Undetectable, Untransmittable, Undefeated) was developed based on information and feedback from the clients in our FY 22 Quality Project. It is a six-week education program based on our current MAI-EIS education course for newly diagnosed /lost-to-care clients. It was adapted to address issues for people who are not newly diagnosed/lost to care, are not treatment naïve, or have ongoing issues managing their viral loads and/or medical appointments. Sessions include HIV evolution, medication management, unpacking old experiences of living with HIV, and addressing shame and stigma. The project supports successfully navigating the continuum of care through education using skill-building methods. The sessions improve the clients’ knowledge of HIV and its continuum of care, identifying and overcoming barriers to care, and medication management. The key population is Long Term Survivors (LTS). The feedback from our FY22 Quality Project was that many LTS were operating with old information, fear of medication, stigma and shame of their diagnosis. After attending the MAI group the clients reported feeling a part of the community and built support systems from the group in addition to decreasing viral loads. The program is six weeks, twice per week for 3 hours. Clients commit to meeting and participating in the group. Knowledge is measured at each session. Viral Load is monitored.

Hillsborough County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 7,464 PLWH or 598 people/100k

Clark County Social Service - Office of HIV (Clark County, NV)

• Program Name: P3, People Purpose Power
• EHE Pillar: Treat
• Type of Intervention: Diagnosis, Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Youth, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 9,694 PLWH or 503 people/100k
• PDF of Program Summary Report

People, Purpose, Power was a training series brought to the community by the OOH to educate on HIV prevention, treatment, cultural and LGBTQ+ humility, and address racism, stigma and discrimination we so often see in HIV services. Since January 2021 we have been partnering with PAETC and Collaborative Research to coordinate subject matter experts to train providers across the community. ""We will continue the implementation the P3 training series designed to establish equity in knowledge on best practices in HIV care and prevention and ignite conversation about local issues that impede progress toward ending Clark County’s HIV epidemic. Presentations focus on innovative Ending the HIV Epidemic (EHE) initiatives, providing services with cultural humility and inclusivity, addressing HIV stigma, racism and health disparities that impact engagement in care, and PWH leadership development. The content is developed with input from the TGA community members, stakeholders and staff to gauge the pulse and trends impacting the jurisdiction."" Surveys and evaluations sent out and collected after each session by partners from Pacific AETC.

Orange County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 7,229 PLWH or 268 people/100k

Sacramento County Public Health (Sacramento County, CA)

• Name of Program: HIV Response Team
• EHE Pillar: Treat
• Type of Intervention:Linkage
• Target Population: PLWH, Black/African American, Hispanic/Latinx, MSM, Youth, Other
• HIV incidence/prevalence from AIDSVu: 4,644 PLWH or 350 people/100k
• PDF of Program Summary Report

This program aims to utilize a data-driven surveillance-based approach to re-engage high-acuity clients in HIV care. The HIV Response Team aims to ensure that 85% of newly diagnosed individuals and their sexual/drug use partners are linked to HIV care within 30 days of diagnosis (with a goal of 10 days) and reengage 5% of those out of care. Communicable Disease Investigators (CDIs) receive a quarterly Out of Care line list from the Office of AIDS. CDIs utilize EHR and additional investigator tools to locate individuals out of care. Then, CDIs work with those individuals linked to care via one of our FQHCs or at our Sexual Health Clinic. Sacramento County Public Health (SCPH) will utilize the HIV Response to reduce out-of-care patients by 5% by 2025. Our current out-of-care number is 1,186.

Riverside County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 10,117 PLWH or 496 people/100k

San Bernadino County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 5,051 PLWH or 282 people/100k

Broward County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 20,350 PLWH or 1,236 people/100k

CAN Community Health (Duval County, FL)

• Name of Program:Ending the HIV Epidemic: A Plan for America
• EHE Pillar: Treat
• Type of Intervention: Diagnosis, Linkage, Retention, Viral Suppression
• Target Population: PLWH, Black/African American, Women, Hispanic/Latinx
• HIV incidence/prevalence from AIDSVu: 6,495 PLWH or 777 people/100k
• PDF of Program Summary Report

This program addresses access to HIV care and treatment in the high-incidence zip codes for people with HIV, both those who are newly diagnosed and those who are not engaged in care and/or not virally suppressed. We hope to address unmet needs and improve client-level health outcomes by increasing the percentage of PWH who achieve and maintain viral suppression. The program deploys mobile medical/testing units in areas of high incidence, prevalence and out-of-care to provide HIV/STI screening, testing rapid access to medical treatment, linkage, and engagement in care.

Miami-Dade County, FL

• Name of Program: Miami-Dade County - Strategy to End the HIV Epidemic
• EHE Pillar: Treat/Respond
• Type of Intervention: Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Youth, Aging Population, Transgender/Nonbinary, People who inject drugs, Other
• HIV incidence/prevalence from AIDSVu: 27,147 PLWH or 1,190 people/100k
• PDF of Program Summary Report

Miami-Dade County (MDC) is home to more than 28,000 people with HIV. Although the local Ryan White Part A Program serves over 9,000 clients, it is necessary to identify and engage people with HIV who are not already connected to medical care and/or who are not continuously virally suppressed and provide them with or guide them to ongoing high-quality HIV care. MDC seeks to improve the client-level health outcomes for all people with HIV by 1) informing the HIV community of available resources and removing barriers to care; (2) increasing organizational capacity of Part A and non-Part A service providers; (3) disseminating information that promotes the benefits of HIV treatment; and (4) improving data infrastructure, sharing, and system linkages to avoid duplication of efforts across funding sources, drive interventions, and measure project successes. EHE Subrecipients utilize evidence-based interventions, as well as local innovative strategies, to address EHE Pillar Two (Treat) and Pillar Four (Respond), as follows: (1) “HealthTec” provides clients with technology that offers access to multiple disciplines, including mental health, case management, and other services, delivering a holistic approach to patient care for those who experience treatment adherence difficulties (transportation, stigma, etc.); (2) “Quick Connect” or interdisciplinary team(s) facilitating linkage to care following the local Test & Treat/Rapid Access (TTRA) rapid start model for people with HIV diagnosed in clinics, doctors’ offices, emergency rooms, hospitals, or urgent care centers; (3) “Housing Stability Services” or housing support—from a “housing first” approach—with job training and placement services to help improve the employability and housing stability of people with HIV; and (4) Mobile GO Teams or support to the Florida Department of Health in Miami-Dade County’s Disease Intervention Specialists to improve linkage to care.

Orange County, FL/Orange County Health Services

• Name of Program: Jail Linkage Program
• EHE Pillar: Treat
• Type of Intervention:Linkage
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 9,353 PLWH or 776 people/100k
• PDF of Program Summary Report

The program aims to identify people with HIV while incarcerated to engage clients and link them to care and support upon release. The goals are to identify people with HIV, increase engagement for justice-involved clients by providing supportive services while incarcerated, and link to care upon release. The Jail Linkage Program focuses on People with HIV (PWH) who are justice-involved in Orange County, FL. Once incarcerated, the Jail Linkage Coordinator meets with the identified PWH and engages them in care. Ryan White Part A and Ending the HIV Epidemic eligibility assessments are completed with the client. Referrals for case management, housing, and medical care are completed. Case managers are encouraged to meet with clients through video visitation to engage in care before release. The client is monitored for medication compliance, and HIV viral load/CD4 laboratory tests are completed during incarceration. The client is provided food bank and transportation services upon release, along with referrals for services. Regular HIV testing is available 7 days a week to identify new or out-of-care clients. Once a reactive test result is confirmed, the Jail Linkage Coordinator assists the client with engaging in care. The program works closely with the Early Intervention Specialist (EIS) to identify any PWH who were not able to connect with the Jail Linkage Coordinator during incarceration. The goal is to increase the percentage of people with HIV who have received medical care for their HIV infection within one month of diagnosis by the goal year. Since January 21, 2023 we have identified 741 people with HIV who were incarcerated in our county jail. 145 newly diagnosed clients were identified and 562 previously positive clients who may have been out of care. 514 clients were linked to care in Ryan White Part A system of care. 60% of clients were virally suppressed at the time of their release from incarceration.

Palm Beach County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 8,153 PLWH or 628 people/100k

Pinellas County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,927 PLWH or 579 people/100k

Cook County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 25,728 PLWH or 586 people/100k

Marion County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,984 PLWH or 625 people/100k

Baltimore City

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 10,252 PLWH or 2,088 people/100k

Montgomery County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 3,943 PLWH or 445 people/100k

Prince George's County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• Info on HIV incidence/prevalence from AIDSVu

Suffolk County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 5,659 PLWH or 832 people/100k

Essex County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 8,883 PLWH or 1,251 people/100k

Hudson County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 4,936 PLWH or 829 people/100k

Mecklenburg County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 6,275 PLWH or 668 people/100k

Hamilton County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 3,159 PLWH or 458 people/100k

Philadelphia County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 16,773 PLWH or 1,264 people/100k

Shelby County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 6,550 PLWH or 864 people/100k

Bexar County / University Health, Operation BRAVE & Ryan White Program (Bexar County, TX)

• Name of Program:Operation BRAVE Care Coordination
• EHE Pillar: Treat
• Type of Intervention:Linkage, Retention, Viral Suppression
• Target Population: Other, MSM, PLWH, Black/African American, Hispanic/Latinx
• HIV incidence/prevalence from AIDSVu:
• 6,913 PLWH or 415 people/100k
• PDF of Program Summary Report

This program bridges the gap of clients being aware of their status by partnering with providers to notify patients of their status, supporting subrecipient MCM with high acuity clients by working as a team unit to support the client. This also includes navigating the limitations of a nurse’s scope of practice, having a limited number of providers to make diagnoses and the heavy workload MCM experiences. Through referral pathways, 80 individuals will be referred for Care Coordination services. Approximately 60 clients will be newly diagnosed or out of care, and the remaining 20 clients will be in care but not virally suppressed. Care Coordinators support clients in developing a care plan, supporting clients to achieve goals in the care plan and transitioning clients to Ryan White once stabilized. The key components and activities with Care Coordination have been to create workflows within the Emergency Department at University Health. We have collaborated with the Emergency Department Providers to establish linkage to care workflows for patients who are newly diagnosed, pending diagnosis, and out of care. Our team utilizes these components during our interactions with clients and when creating care plans. In these care plans, we are linking patients to care, creating self-independence, and addressing client needs. We can track Care Coordination’s progress by creating internal and external data systems, such as HIV database and EHE PTG. Measurable outcomes for Care Coordination include total number of referrals, linkage to navigation, and linkage to care. In collaboration with Nurse Supervisor, the Sr. Quality Data Analyst reviews trends of previous funded year data to increase achievable goals for the upcoming funding year.

Dallas County Health & Human Services EHE Program (Dallas County, TX)

• Name of Program: EHE - Care Navigation
• EHE Pillar: Treat
• Type of Intervention: Dashboards/Visualization, Performance Measures, Retention/Adherence, Housing Assistance, Cluster Detection, Medication Access, Stigma Reduction, Support Services, Mobile/Texting, Re-Engagement, Data-to-Care, Peer Support, Rapid Start
• Target Population:All - PWID, Black/African American, Transgender/Nonbinary, Spanish speakers, Aging Population, Hispanic/Latinx, Women, Youth, PLWH, MSM, Other
• HIV incidence/prevalence from AIDSVu: 19,597 PLWH or 926 people/100k
• PDF of Program Summary Report

The programs aim is to establish a current and consistent process to support linkage of individuals living with HIV to medical care with collaboration of EHE Community Health Workers, the county Sexual Health Clinic and STI/HIV Division. By March 2024, the EHE Division aimed to link 90% of clients to HIV care up from a baseline of 76%. Our goals were to establish baseline data on linkage to care, consistently track this data over time, and set improvement targets, such as increasing baseline linkage to care by 5% through streamlined workflows. Collaboration and streamlined workflows led to significant improvements in linkage to care rates and a reduction in the time required for linkage. From August to December 2023, the initial collaboration phase with the Sexual Health Clinic (SHC) and Disease Intervention Specialists (DIS) resulted in an average linkage time of 17.1 days for newly diagnosed HIV patients. Building on this foundation, from January to July 2024, continued refinement of Standard Operating Procedures (SOPs) and enhanced communication efforts yielded a remarkable 62% reduction in average linkage time, bringing it down to 6.5 days. These efforts significantly impacted patient care, as evidenced by an increase in the overall linkage to care rate for SHC patients, which rose from 88% to 97%. This improvement underscores the success of the Ending the HIV Epidemic (EHE) Quality Improvement (QI) project in enhancing patient outcomes through better coordination and efficient processes.

Harris County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 27,828 PLWH or 724 people/100k

Tarrant County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 6,407 PLWH or 367 people/100k

Austin Public Health (Travis County, TX)

• Name of Program: Rapid stART Initiative
• EHE Pillar: Treat
• Type of Intervention: Linkage
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Transgender/Nonbinary
• HIV incidence/prevalence from AIDSVu: 5,262 PLWH or 473 people/100k
• PDF of Program Summary Report

The HIV Resource Administration (HRA) at Austin Public Health (APH), through its Rapid stART Initiative, responds to gaps in linkage to quick, timely Antiretroviral Therapy after a community member receives an HIV diagnosis. The goal of this innovation is as follows: when an individual tests positive for HIV, they are connected to a provider and prescribed Antiretroviral Therapy within 72 hours of diagnosis. By doing so, people living with HIV (PLWH) will be more likely to achieve viral suppression quicker and less likely to transmit HIV to other people. HRA created Rapid stARt Service Standards and procedures for the Rapid stART program that align with best practices. HRA established connections between key pharmaceutical companies in the HIV space (i.e., Gilead Sciences, ViiV Healthcare and Johnson & Johnson) with community-based providers in Austin who serve PLWH. As a result of this collaboration, the pharmaceutical companies provide Rapid stART starter packs for free to sub-recipients and their clients. After the first week, the medication moves to a 30-day prescription. As EHE sub-recipients have been improving linkage to care through Rapid stART, HRA has been increasing awareness through its media campaign. Launched in August 2024, the EHE Media Campaign uses brand language and imagery to promote the message that HIV can become undetectable and untransmittable (U=U) through Antiretroviral Therapy. The campaign includes an EHE website, social media posts, YouTube videos, press releases and various forms of collateral available for community outreach.

Seattle/King County, WA

• Name of Program: HIV Mobile Outreach Team
• EHE Pillar: Treat
• Type of Intervention: Linkage
• Target Population: MSM, Black/African American, Hispanic/Latinx, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 7,182 PLWH or 372 people/100k
• PDF of Program Summary Report

The HIV Mobile Outreach Team (HIV MOT) was created to reach PWH who are virally unsuppressed, not engaged in care, and facing complex barriers to care such as behavioral health disorders, housing instability, and/or justice involvement, largely located in Seattle and south King County. HIV MOT receives referrals from low-barrier clinics and community-based organizations. The team determines eligibility (virally unsuppressed and living/staying in King County). The HIV-MOT team uses public health surveillance data to identify and contact candidates in via phone, text, field/inpatient visits, and mail. All candidates receive weekly outreach attempts for at least 90 days. Once engaged, the team emphasizes rapport and trust building, working with clients to set goals and define their preferred level of support. Often, clients show movement in reaching personal goals unrelated to their health, leading them to add goals that include linking to medical/HIV care.

Seattle/King County, WA

• Name of Program: Expanding Low-Barrier Care Clinics
• EHE Pillar: Prevent/Treat
• Type of Intervention: Diagnosis, Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Spanish speakers, Women, Youth, Aging Population, Transgender/Nonbinary, People who inject drugs
• HIV incidence/prevalence from AIDSVu: 7,182 PLWH or 372 people/100k
• PDF of Program Summary Report

Low-barrier services include walk-in access to sexual health services, PrEP, HIV care, social, mental health, and substance use services. Some sites offer incentives to help people engage in HIV prevention or care when meeting their basic needs can otherwise make it too difficult to do so. Harborview Medical Canter (HMC) provides status-neutral/whole-person care services through a low-barrier (walk-in) model. Clinical services include primary care, wound care, STI/HIV prevention and treatment, substance use services, and mental health services. Additionally, they provide patient coordination and medical case management. The CBOs (Aurora Commons and Catholic Community Services) provide outreach and engagement, housing support and case management, psychosocial support, and drop-in day center services. Linkage to care (1, 3 and 6 months), linkage to ART (3 and 6 months), viral suppression (6 and 12 months), HIV testing, and PrEP prescriptions are tracked.

Seattle/King County, WA

• Name of Program: EHE Emergency Department Collaborative 
• EHE Pillar: Diagnose/Treat
• Type of Intervention: Diagnosis, Linkage, Retention, Viral Suppression
• HIV incidence/prevalence from AIDSVu: 7,182 PLWH or 372 people/100k
• PDF of Program Summary Report

EHE created the Emergency Department Collaborative to increase HIV screening in King County Emergency Departments. Emergency departments treat a large number of people who do not access regular primary care, including many people at risk for HIV. EHE is helping to identify people who have not been diagnosed with HIV yet, as well as those who have fallen out of care, to help engage or re-engage them in HIV treatment, improving not only their health but preventing their ability to transmit HIV to others. The goal is to increase HV case finding in emergency departments.

Bronx County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 27,313 PLWH or 2,329 people/100k

Kings County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 26,096 PLWH or 1,187 people/100k

New York County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• 26,131 PLWH or 1,859 people/100k

Queens County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population

(Short 1 paragraph blurb summarizing program)

• Link to PDF of program summary report
• Info on HIV incidence/prevalence from AIDSVu

Atlanta Department for HIV Elimination (Fulton County, GA)

• Name of Program: Department for HIV Elimination, Fulton County Government
• EHE Pillar: Treat
• Type of Intervention: Linkage, Retention, Viral Suppression
• Target Population: MSM, PLWH, Black/African American, Hispanic/Latinx, Women, Transgender/Nonbinary
• HIV incidence/prevalence from AIDSVu: 16,384 PLWH or 1,802 people/100k
• PDF of Program Summary Report

The goal of our program is to support individuals as they move along the HIV Care Continuum with the ultimate goal of attaining viral suppression. This will be achieved by engaging persons living with HIV who are not in care (newly diagnosed, previously diagnosed but never in care, and those who have fallen out of care) as well as PLWH who are not virally suppressed (including those in care) and rapidly connecting them to a comprehensive continuum of high-quality care and treatment services. Through EHE we fund organizations to provide extended hours of service outside of traditional 9-5 business hours. Clients can receive services between 8a-8p and on weekends at many locations. Through EHE we were able to expand telehealth services so clients were able to continue their care in the midst of the COVID-19 pandemic, we provide hormone therapy for our transgender clients, and our agencies implement innovative interventions that link clients to care and find those that have dropped out of care to get them back into services. Other services offered include medical care, mental health and substance use services, oral health care, housing, case management, support groups, food and nutrition services, medical transportation, emergency financial assistance, health insurance navigation, legal services, and translation services to our clients that are non-English speakers. ""For the grant year 2023, we served 4,093 clients; this is a 50% increase compared to FY22. Over 16,000 services were provided. 175 individuals were linked to care within 30-days and of our 4,093 clients 79% were retained in care, 99% were prescribed ART and 82% became virally suppressed.

Cobb County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population
• 3,653 PLWH or 565 people/100k
• Link to PDF of program summary report

(Short 1 paragraph blurb summarizing program)

DeKalb County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• 9,140 PLWH or 1,443 people/100k
• Target PopulationLink to PDF of program summary report

(Short 1 paragraph blurb summarizing program)

Gwinnett County

• Name of Program
• EHE Pillar
• Type of Intervention (by continuum of care categories)
• Target Population
• 3,347 PLWH or 423 people/100k
• Link to PDF of program summary report

(Short 1 paragraph blurb summarizing program)