Access to Care (A2C) Project Summaries

Philadelphia, PA

ActionAIDS, a Philadelphia-based HIV/AIDS service organization, will implement an intensive case management program designed to increase the rate of retention in health care for individuals who have been recently released from the Philadelphia Prison System. During the formative phase of this program, ActionAIDS will design an acuity assessment instrument that will identify clients at intake who present the greatest risk of being lost to care. These clients will then receive intensive "Care Coach" case management services, expedited housing and behavioral health services, and related support to remain engaged in care. ActionAIDS will be joined by three other nonprofit service providers to help transform the delivery of services to recently incarcerated clients, as well as services to other clients who have mental health or drug and alcohol issues and who lack stable, affordable housing. The primary goals of the project are to:

  • Identify sub-optimally engaged PLWH/A and link and retain them in care
  • Increase the number of formerly incarcerated PLWH/A who obtain/maintain safe and affordable housing
  • Increase the number of formerly incarcerated PLWH/A who participate in back-to-work programs
  • Reduce recidivism for formerly incarcerated PLWH/A


AIDS Action Committee 
Boston, MA

The primary goal of LEAP 2.0 is to improve the health of PLWH/A by providing comprehensive bio-psycho-social support from crisis to stability and self-sufficiency. A collaborative effort between AIDS Action Committee of MA (AAC) and Partners in Health’s Prevention and Access to Care and Treatment (PACT) program, LEAP 2.0 (Linking, Educating, and Advocating with Peers) aims to increase the number of PLWH/A who are linked to and retained high quality HIV medical care and supportive services. The LEAP 2.0 Integrated Advocacy Team minimally consists of a Client Advocate, a Peer Leader, and a non-traditional Mental Health Specialist. Others may join the team depending on individual client needs. LEAP 2.0 priority areas are:

  • Linkage to and retention of PLWH/A in HIV medical care
  • Enhanced and expanded access and retention in supportive services (including non-traditional mental health services and self-management support groups)
  • Improved self-sufficiency of PLWH/A who are not engaged in care through participation in benefits, treatment adherence, and workforce readiness workshops
  • Expanded continuum of care for PLWH/A to better support long-term self-sufficiency


AIDS Foundation of Chicago 
Chicago, IL

The Connect2Care (C2C) is a collaboration between AFC and four experienced HIV/AIDS organizations to establish regional C2C hubs that conduct outreach and networking activities to create seamless systems from HIV diagnosis through ongoing care. The overarching goal of the C2C project is to increase access to and consistent retention in HIV care for People living with HIV/AIDS. Our program model is combination of system level and program level enhancements which makes the use of quasi-experimental design with equivalent groups neither feasible nor desirable. The key evaluation questions relate to implementation and outcomes monitoring, and it is essential that the evaluation feeds data back to the program so as to allow potentially major changes in program design and implementation in response to lessons learned. The four primary intervention components for the project include:

  • System level enhancements
  • Client level outreach
  • Linkage to care
  • Client level education.


Amida Care & New York Community Trust (Social Innovation Fund/Positive Charge)
New York, NY

ACCESS NY is an innovative model that combines best practices for getting HIV POSITIVE clients into care with best practices in expanding clinic access to outreach and system redesign of primary medical care for Medicaid-eligible, HIV positive clients. The goal of the model is to bring clients into medical care and then to retain them in care. To achieve these goals, ACCESS NY guides providers in redesigning systems of care delivery that expand appointment access, improve patient flow, and create a team-based care delivery model. System redesign will be affected by engaging seven HIV primary care providers in a Learning Collaborative using the Institute for Health Care Improvement’s quality improvement model. Amida Care members eligible for ACCESS NY will have dropped out medical care for at least six months or come on to the plan without an identified primary care provider. Once enrolled, clients who have yet to established a true medical home will be assisted in the process by Health Navigators, who will walk the through connecting to care by meeting them where they are at both literally and figuratively. Primary areas of focus are:

  • Enhanced outreach
  • Care coordination
  • Follow-up
  • Peer support


AIDS Project Los Angeles
Los Angeles, CA

The Care and Access Network represents a partnership among leading HIV/AIDS service organizations, APLA, Northeast Valley Health Corporation and REACH LA, in Los Angeles County (LAC). All of the agencies provide a wide variety of clinical, support, and prevention services to a diverse client base across the vast geography of LAC. Each of the partners demonstrates a long history of engaging racial/ethnic and sexual minorities in the continuum of care. In addition, many of the agencies provide HIV counseling and testing services to high-risk populations and are connected to a broader network of service providers in their individual communities, inclusive of HIV primary medical care. Patient Navigators help PLWHA address individual barriers to care in order to increase access and retention in medical care, access treatment, and participate in other supportive services (e.g., case management, housing, food and nutrition services, mental health, and HIV risk reduction programs) to enhance and maintain engagement in care, and to reduce the incidence of new HIV infections by reducing the community viral load. Strategies for reducing community viral load include PNs advocating for earlier initiation of ART as well as helping clients improve adherence.


Christie’s Place
San Diego, CA

CHANGE 4 Women functions as a network of care model. It is designed to improve timely entry, access to and retention in HIV care for women living with HIV in San Diego County, with an emphasis on women of color. The intervention has two levels of innovation—with individuals and among service agencies. The individual-level element focuses on increasing the number and capacity of peer navigators and the CP peer coordinator to do outreach to and provide support for HIV+ women. Also, through geo-mapping viral loads based on project client and anonymized surveillance records, peers will prioritize outreach services. The agency innovations include CP’s ‘one-stop shop’ approach to improving client knowledge of their health and social service situation and access to care via medical home electronic record access. Other systems-level innovations include increased formalization and coordination among the major HIV health care agencies in San Diego. The project goals are to:

  • Improve underserved women’s access to and retention in comprehensive HIV care
  • Improve utilization of HIV medical care and treatment for HIV+ women
  • Strengthen health care and social services systems and community linkages through innovative and replicable interventions and new collaborations that improve engagement and retention in care by HIV+ women.


Damien Center
Indianapolis, IN

Damien CareLink will provide coordinated HIV services and linkage to care for HIV+ individuals who are currently not in care. According to the Centers for Disease Control and Prevention, timely linkage to care has a variety of benefits, including delaying disease progressions and increasing positive health outcomes, reducing transmission and therefore preventing new infections, decreasing health care expenditures, and keeping community viral loads low. Numerous and complex barriers to care linkage to exist, and may include issues such as mental health and substance issues, fear and stigma, homelessness, lack of co-located facilities, and many others. Damien CareLink will address these and others barriers for the target populations, which include HIV+ individuals who did not receive post-test counseling who were tested confidentially and those who have been lost to care, African Americans between the ages of 18-44 and Hispanics between the ages of 18-44. The priority areas to be addressed in accomplishing these goals include:

  • Early HIV detection
  • Connecting those PLWH/A but not in care, into care
  • Identifying those who are HIV positive, yet unaware of their HIV status
  • Referrals of HIV negative individuals to HIV prevention, health education, and risk reduction


Louisiana Public Health Initiative (LPHI
Baton Rouge, LA

Supported by AU’s Social Innovation Fund, LPHI will also serve as the lead agency and evaluator for the Louisiana Reentry Initiative (LRI). The overall goal of the LRI is to link and retain formerly incarcerated individuals living with HIV infection in Louisiana with an initial focus in the Baton Rouge. The project goals are to:

  • Strengthen the current linkage and retention system for formerly incarcerated PLWH/A
  • Implement a social stabilization intervention to link/retain formerly incarcerated PLWH/A
  • Create broader statewide dialogue surrounding the impact of stigma on access and retention in care
  • Promote the expansion and sustainability of retention programs for formerly incarcerated PLWH/A


Medical AIDS Outreach of Alabama 
Montgomery, AL 

The SIF-funded “Access to Care” HIV/AIDS-telemedical program, spearheaded by MAO; Whatley Health Services, Inc.; and AIDS Action Coalition – Huntsville, uses encrypted, high-speed data connections, spoke-site clinical support, and high-definition video/diagnostic tools, to allow urban-based interdisciplinary teams to hold real-time encounters/consultations with rural consumers and rural providers throughout the state. In addition to high-quality medical care, these services include real-time Spanish-English translation assistance, real-time social work consults, real-time housing assistance, real-time pharmacological consults, and real-time case management encounters - services to which the rural communities touched by this initiative would otherwise have little or no access.


North Carolina Community AIDS Fund
Durham, NC

The North Carolina Positive Charge Initiative is working with partners in three areas of the state (rural northeast, suburban coastal southeast, and urban Mecklenburg County) to identify and bring into care people who know their HIV+ status but are not engaged in medical care. Key Partners in each area of the state have a team of 2-3 specially trained part-time peers, called Access Coordinators. They spend approximately half of their time working in the community identifying people who are out of care and about half of their time working within the HIV service system. Our target population is anyone living with HIV that is disengaged or inconsistently engaged in HIV medical care. Access Coordinators receive the PETS (Peer Education Training Site) training as well as a specially designed Access Coordinator Training to prepare them to do this work. Additional support is provided through annual trainings of the Access Coordinator cohort and monthly conference calls.


St. Louis Effort for AIDS
St. Louis, MO

The BEACON Project seeks to locate and return to care some of the 2,384 PLWHA in the Saint Louis region with no evidence of HIV primary care with the past year. The BEACON Project is a collaboration between the City Health Department, Saint Louis Effort for AIDS, and Washington University’s Project ARK. When PLWH/A who are out of care are identified, they will receive services from one of the Care Navigation Teams. Each team is made up of an Engagement Coordinator (who also serves as their Ryan White Case Manager), two HIV+ Peer Advocates, and a shared Community Nurse. BEACON clients will have

  • Access to Peer Advocates to manage barriers of stigma, disclosure, and fear
  • Support from Peer Advocates and Engagement Coordinators who assist clients in navigating social service resources
  • Access to the Community Nurse for education and support in managing their treatment for HIV and any other medical conditions


Washington AIDS Partnership 
Washington, DC

Positive Pathways is a program in the District of Columbia that assists HIV-positive African Americans living in Wards 5-8 to participate with HIV medical care and supportive safety net services, with a particular focus on women and their partners. Led by Washington AIDS Partnership, Positive Pathways is a collaboration between more than 15 community partners and the DC Department of Health. Through a network of 12 trained peer Community Health Workers (CHWs) placed in community and primary care settings, Positive Pathways works to support program participants to take full advantage of HIV medical care and other community services to improve their health and quality of life. Community Health Workers work at their employing organizations and in the community to identify individuals who are HIV-positive and not receiving HIV medical care in order to build trust and inform them about living with HIV, to provide personalized assistance to help them enter medical care, and to support them throughout the early part of their care until they are fully involved. Peers utilize their unique position to address barriers to care that can present challenges for other medical professionals. These CHW professionals provide trust-based information and education; help clients overcome fear, denial and stigma; conduct outreach and support deep in the community; take the time to walk clients through the often overwhelming healthcare system; and help clients strategize to manage the logistics of caring for oneself in the context of a complicated life.


University of Alabama/Birmingham 
Birmingham, AL

Birmingham Access to Care (BA2C) is a collaborative effort between UAB 1917 Clinic and Birmingham AIDS Outreach (BAO). HIV primary care and social service providers have, for years, recognized the profound public health implications of the "lost to follow-up," or fallen out of care, population. BA2C may have an impact not only for the individual lost to follow-up it serves, but also at the population level to reduce racial/ethnic disparities in HIV outcomes. Improving engagement in HIV care for the HIV-+ population not currently seeking primary care treatment may have other beneficial effects for the public health. Reductions in risk transmission behaviors among individuals linked to care and the beneficial effects of ART in reducing HIV viral load and transmissibility may result in decreased secondary cases of HIV infection if the program is successful in improving linkage, retention, and re-engagement in HIV care. BA2C will assemble and create a team of 2 Licensed Board Social Workers, data programmers, and project supervisors to focus on the following goals:

  • Increase re­engagement/linkage to HIV primary care among HIV-infected individuals lost to follow-up
  • Obtain information regarding individual-level facilitators and barriers to HIV primary care linkage
  • Increase the proportion of individuals lost to follow-up annually retained in comprehensive and coordinated outpatient medical services.