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Targeted HIV Outreach & Intervention Models for Underserved HIV-positive Populations Not In Care


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The Outreach Initiative was a two-phase, five-year program supporting multi-year demonstration projects to implement, refine and evaluate innovative outreach strategies for bringing PLWH into HIV primary care. In September 2001, seventeen individual projects were funded for Phase 1 (project years 1-2). During this phase, the projects implemented their outreach and intervention programs; conducted a local evaluation of those strategies; and planed activities to enhance or modify their programs for Phase 2 (project years 3-5). Grantee planning activities included refining intervention models based on the findings of their local evaluation; adjusting their local evaluation plans as needed; and participating in a multi-site evaluation.

Identifying effective models of outreach to underserved people living with HIV (PLWH) who are not receiving care is a critical concern in responding to the changing AIDS epidemic. Advances in the treatment of HIV/AIDS have slowed both AIDS death rates and the progression of disease for many PLWH. However, vulnerable and marginalized groups are not benefiting from these advances as much as other populations. Outreach strategies that worked in the early years of the epidemic may not improve access for people who have been historically underserved and marginalized and who mistrust the medical care system. Populations with the highest HIV infection rates have a correspondingly greater need for treatment, yet other behavioral and service delivery factors such as cultural and linguistic biases, racial and gender discrimination and lack of insurance have a profound influence on access to medical care.

Creative and intensive outreach efforts can assure timely and continued treatment for people facing persistent barriers to access of care, and new, innovative outreach strategies have been developed to engage and retain underserved PLWH in care. These include street outreach, mobile vans, community outreach workers, peer educators, promotores and patient navigators, all focused on reaching those who are out of care. Outreach approaches have emerged that seek to engage clients by addressing them on their own terms, providing them with tangible benefits that meet their subsistence needs before addressing their health care needs. In these frontline approaches, each incremental step that brings a person living with HIV infection closer to primary HIV care is seen as progress.



Grants for this initiative were awarded to the organizations listed below. The abstracts provide a brief description of their project.

Access Community Health Project, Chicago, IL
Community Health Outreach Program

Target Population: Active substance abusers, commercial sex workers, individuals being released from jails and prisons, and other hard-to-reach individuals chronically not in care.

This project evaluated a current intervention that provided primary HIV care in community locations, and linked HIV infected individuals to social services. Intervention activities during Phase 1 included "inreach" to clients of partner agencies to ensure enrollment in care; provision of primary care health services, benefits counseling, and referrals; and outreach to high-risk populations in the community. Intensive case management was added and evaluated during Phase 2. Organizational partners included a local needle exchange program; social service agency for commercial sex workers; an agency serving men who are leaving incarceration; a consortium of HIV case management programs in Northern Illinois; two drug treatment programs; an established AIDS service organization; and an emergency food bank for HIV infected persons. 


Health Services Center, Anniston, AL
Targeted HIV Outreach Model Development

Target Population: Uninsured African-Americans living with HIV disease in rural Northeast Alabama

This project evaluated an intervention seeking to bring the target population into care through activities which educate about susceptibility and severity of HIV infection; the potential benefits of enrollment into care; and strategies for overcoming barriers to care. Phase 1 activities consisted of intensive counseling at intake about the experience of symptomatic HIV infection; viewing of an educational video regarding HAART; counseling for the management of therapeutic side effects; obtaining support services; and meeting survival needs.  In Phase 2, the intervention sought to enhance enrollment and retention into care by deploying current clients as peer counselors, and training them to become key influencers in local social networks. Jacksonville State University, located in the project's geographic target area, served as an organizational partner.


Blacks Assisting Blacks Against AIDS, St. Louis, MO
Case Finding Initiative

Target Population: HIV infected African-Americans living in St. Louis, MO, and East St. Louis, IL.

This project evaluated the Case Finding Initiative that targeted African-American neighborhoods in St. Louis and East St. Louis through augmented outreach, counseling and testing, and case management services. In Phase 1, the project sought to increase the number of persons enrolled in case management; improve client self-efficacy; enhance positive beliefs in health care services; improve knowledge of treatment regimens; and advance provider-client communications. In Phase 2, the project implemented a refined Case Finding Initiative model based upon evaluation findings. Key organizational partners were local health departments in St. Louis, MO, and East St. Louis, IL, and St. Louis University.


Care Resource, Coral Gables, FL
Treatment Access Project

Target Population: African-American and Latino HIV-infected adults in the downtown, northeast, Hialeah, Opa-Locha, and Miami Lakes neighborhoods of Miami-Dade County

This project focused on an intervention of concentrated outreach and physician referrals that sought to increase use of services by persons not in care or sporadically in care and improve retention in care. During Phase 1, HIV- infected persons not in care were enrolled in a case management-based treatment intervention through focused outreach, provider referral, and social marketing of the agency's program. In Phase 2, the intervention also sought to increase  adherence to established care plans; engagement in services as a result of referrals; satisfaction with case management services; participation in preventative health care services; and ongoing participation in the program. The University of Miami's Department of Epidemiology and Public Health served as an organizational partner.


Charles R. Drew University School of Medicine and Science, Los Angeles, CA
Focused Intervention and Access for HIV Positive Minorities

Target Population: HIV infected persons of color, especially African-Americans and Latinos

This project evaluated an intervention in the grantee's OASIS clinic that used HIV-infected peers to identify HIV-infected individuals and bring them into treatment and/or prevention interventions. Activities during Phase 1 consisted of outreach to bring clients into case management services; enrollment in primary care; referral to outside support services to assist clients with overcoming barriers to care; and use of client incentives to maintain engagement in care. Activities in Phase 2 consisted of implementing and evaluating a refined intervention that sought to bring clients into treatment earlier; test and treat for co-morbidities; and increase treatment adherence.


Fenway Community Health, Boston MA

Target Population: HIV-infected Men of Color who have sex with other men, especially those who do not identify as gay or bisexual; male commercial sex workers; male prisoners or ex-offenders; male substance abusers; and/or transgender or transsexual persons.

This project evaluated case finding and outreach interventions that were implemented by the grantee or in conjunction with organizational partners. Phase 1 activities consisted of outreach to persons who show evidence of high risk behavior and referral to the Health Center for risk reduction services; screening of all Center clients with regard to sexual and substance abuse histories to assess risk for HIV infection; counseling and testing of all persons with high risk profiles; referral into care for those who are HIV infected; prompt enrollment of referrals into case management; patient education by health care providers with regard to the nature of HIV infection; and telephone and/or in-person follow-up by case managers or outreach workers to those who miss appointments or who become lost to care. Phase 2 refined the intervention by strengthening staff capabilities to maintain patients in care and adding use of HIV infected peers in outreach work. Organizational partners in the project included Men of Color Against AIDS, Span, and Victory Programs.


Harm Reduction Services, Inc., Sacramento, CA
Peer-Based HIV/AIDS Outreach and Case Management for Under Served Populations

Target Population: Injection Drug Users, Commercial Sex Workers, and Others at High Risk

This project evaluated the effectiveness of a continuum of street outreach, education, counseling and testing; transitional street side case management; and ongoing office-based care. It emphasized reaching those in the target population who faced barriers of mental illness, extreme poverty, homelessness, and cultural blocks. Phase 1 activities included street outreach to build rapport, assess risk, initiate risk reduction, and enrollment in comprehensive HIV specialty care and in case management. Specific objectives included helping the target population to progressively reduce its incidence of risky behaviors; gain a more positive impression of the healthcare system and knowledge of how to use it; and remove logistical barriers to obtaining services. Phase 2 continued these activities with an enhancement to provide easier access to medical care for people in remote neighborhoods and/or those with significant barriers. The Center for AIDS Research served as an organizational partner in the project.


The Miriam Hospital, Providence, RI
Project Bridge

Target Population: Seropositive ex-offenders recently released from incarceration.

This project evaluated an existing intervention (Project Bridge) with ex-offenders to assess use of primary care and barriers to care, current health outcomes, and the impact of available support services. Phase 1 activities sought to reduce relapse among substance abusers; increase the use of clinical services; and teach new skills that will help to stabilize life situations. In Phase 2 the intervention was refined by adding skills-building groups focusing on health-seeking behaviors; motivational interviewing for engaging in substance abuse treatment; and extending the enrollment period to cover brief periods of reincarceration. The Phase 2 intervention also added detainees in the local jail to the target population. Collaborators included AIDS Care Ocean State, the AIDS Project of Rhode Island, the Brown University AIDS Program, the Stanley Street Treatment and Resource Center, the local Traveler's Aid Society, and Family Services, Inc.


Montefiore Medical Center, Bronx, NY
Outreach and Intervention Program to Reach HIV Infected Persons Living in Bronx, NY, Single Room Occupancy Hotels

Target Population: Residents of Single Room Occupancy (SRO) Hotels

This project evaluated and refined a program of integrated harm reduction and medical outreach in Bronx, NY, which sought to transform sporadic health care users into regular and continual users, and to retain participants in care. In Phase 1, the project sought to to engage the target population in services, create a complete initial patient medical data base, and develop treatment plan for those enrolled. Phase 2 activities focused on refining pre-engagement outreach activities, expanding in-home medical and mental health services, and retaining participants when they were permanently housed. Goals for Phase 2 included increasing participant stability in adherence to treatment; improving mental health outcomes, reducing disease progression, and improving overall quality of life. The project's organizational partners were Montefiore Medical Center's Department of Family Medicine and Community Health, and CitiWide Harm Reduction, Inc.


Multnomah County Health Department, Portland, OR
Care Link Evaluation

Target Population: Persons living with HIV infection or AIDS who have not received care within six months of diagnosis or who have fallen out of care.

This project evaluated the effectiveness of Care Link, an outreach intervention that used peers to contact individuals, break down barriers to care, and motivate individuals to seek care. Phase 1 activities evaluated the Care Link model and also included a community planning process to determine refinements to be implemented and evaluated during Phase 2. Phase 1 objectives included increasing client knowledge about HIV and treatment options; client self-efficacy; client self-support; client skills and motivation; and client readiness to enroll in services. Cascade AIDS Project served as the organizational partner in this project.


University of California, Los Angeles Schools of Medicine & Public Health, Los Angeles, CA
Intervention for Outreach and Access to Care

Target Population: Commercial sex workers, runaway youth, the homeless, undocumented workers, gang members, teen parents, women of childbearing age, adult and adolescent MSMs of color and transgendered/transsexual persons of color in the South Central, Hollywood, West Hollywood, East LA, and downtown neighborhoods of Los Angeles.

In Phase 1, this project evaluated an intervention that provided testing, counseling, and care services to the target population, with the objectives of increasing positive attitudes toward health care; belief in the efficacy of treatment; perceived availability of health care services; and use of health care services. In Phase 2, the project implemented a refined intervention featuring enhanced outreach and case-management, with the goal of improving access to care and health outcomes as a result of services provided. Drew University's Mobile HIV Outreach Program (MoHOP) served as an organizational partner.


University of Miami School of Medicine, Miami, FL
Caring Connections

Target Population: Seropositive women and children who are not in care or are underserved in the Miami Family Care Program of the University of Miami and Jackson Memorial Medical Center.

This project conducted a structural, process, output, and outcome evaluation of the Miami Family Care Program and developed a refined intervention (Caring Connections) to improve enrollment and participation in HIV care. The cMiami Family Care Program was based upon a social work case management model, and sought to enroll women in primary care within six weeks of receiving a diagnosis of HIV infection; maintain them in care with a minimum of three primary care visits per year; re-enroll those who were lost to care; and  reconnect with women who may be "lost in the system" because they were receiving care from other providers in the HIV care system. The objectives for children in Phase 1 were to enroll them in care within six weeks of receiving a diagnosis of HIV infection, and screen and monitor children born to HIV infected mothers with a minimum of three primary care visits per year. The Phase 2 intervention was derived from CDC models for HIV prevention that emphasized stages of behavioral change. Phase 2 objectives were to increase the minimum number of primary care visits for each target population to four; increase adherence to medication regimes and scheduled appointments; and increase the percentage of pregnant women who adhere to ZDV protocols before and after giving birth. Organizational and community partners included the University of Miami's Departments of Psychiatry and Behavioral Sciences, Obstetrics and Gynecology, and Pediatrics; the local Salvation Army; a homeless services provider; two African-American churches; Mujer, Inc.; two Haitian community organizations; and local substance abuse treatment providers.


University of Texas Health Sciences Center, San Antonio, TX&
Peer-Based Targeted HIV Outreach and Intervention

Target Population: HIV African-American and Latino Men of Color in San Antonio, TX, who are Sexually Active with other Men (MSM)

This project evaluated an existing intervention that sought to identify and bring the target population into medical care. In Phase 1, the intervention employed HIV-infected MSM of color peer outreach workers to link MSM who were not in care into the existing medical care and social services system, and reestablish links to persons who have been lost to care. It sought to bring MSM into services earlier in their disease stage and maintain their participation in the care system. Specific objectives included enhancing client perceptions about the importance of early entry into care, and improving coordination between outreach, counseling and testing, and medical care. In Phase 2, the project refined the intervention based upon evaluation findings from Phase 1. BEAT AIDS, a local service provider, and FFACTS, a local clinic, will be organizational partners in the project.


University of Washington, Department of Psychiatry, Seattle, WA
Konnect II Client Advocacy Program

Target Population: Seropositive adults of color who are not enrolled in primary care, or are sporadic users of primary care.

This project evaluated a community-based intervention, Konnect II, which used Client Advocates and Peer Supporters to engage the target population in care. It sought to improve health status, reduce high-risk behaviors, and improved  functioning in areas of personal relationships and employment. In Phase 2, the intervention implemented refined strategies to address the unmet needs and barriers to primary care identified in the Phase 1 evaluation, using an Assertive Community Treatment team approach. Enhanced services for Phase 2 included additional community nursing, psychiatric services, and specialized medicine. The major organizational partner in the project were the People of Color Against AIDS Network, which conducted theKonnect II intervention.


Wayne State University, Detroit, MI
Evaluating the Horizons Project's Targeted HIV Outreach and Interventions

Target Population: HIV-infected youth who are not enrolled in primary care

This project evaluated the Horizons Project, another intervention funded by SPNS, in which outreach activities, peer advocacy, individualized case management, and mental health services were provided to decrease levels of mental health distress and substance abuse among HIV infected youth and improve their overall health and well-being. In Phase 1, the project sought to increase the number of HIV infected youth reached via outreach; increase the number who enroll with Horizons for case management and peer advocacy; and increase the number of those lost to care who were contacted through outreach activities. Phase 2 activities consisted of implementing a revised Phase 1 model and adding the treatment mechanism of Motivational Interviewing, with the goal of enhancing engagement in treatment. Key organizational players in the project were the Children's Hospital of Michigan and the Michigan Department of Community Health.


Well Being Institute, Detroit, MI
Women's Access to Care Program

Target Population: HIV-infected women who have been lost to follow-up in health care, and are predominantly substance abusers, mentally ill, African-American, living in poverty, and/or facing other barriers to obtaining health care.

This project evaluated the Personalized Nursing LIGHT model as it helped women cope with barriers to care and sustain involvement in care. During phase 1, the project evaluates the model's impact in two programs, an HIV adherence study and a sex worker study, funded by other sources. The project sought to identify correlates and antecedents of success and weakness in these programs, and to refine an intervention used in Phase 2, which will undergo more intensive evaluation. The Phase 2 intervention sought to improve the recruitment rate of the target population; increase the number of women retained in the project; improve their mental health; decrease their substance abuse; and improve their individual overall well-being. Partners in the project included the Infectious Disease Clinic at the Wayne State University School of Medicine, Detroit Central City Community Mental Health, Inc., and the Detroit LIGHT House Substance Abuse Treatment Program.


Whitman-Walker Clinic, Washington, DC
Retaining HIV+ Clients in Care

Target Population: Adult Latinos/Latinas who are seeking HIV primary care, and African-American adults who know of their HIV infection, but only sporadically seek care or have dropped out of care.

This project evaluated two interventions: an Adherence Clinic, and a Latino/Latina Care project. In Phase 1, the project sought to include pre-appointment phone calls to assess and remove barriers to service; telephone and in-person follow-up by staff when appointments are missed; outreach to clients being seen in emergency rooms; outreach to other HIV service organizations that do not provide clinical services; monitoring of paperwork related to ADAP, Medicaid, and SSI; client advocacy; and accompanying clients to appointments for support services. Phase 1 activities also included refining the interventions based upon evaluation findings, and recruitment of additional participants in the refined intervention, with an emphasis on meeting mental health and addictions treatment needs.


Boston University School of Public Health, Boston, MA
(CORE Evaluation and Technical Assistance Center)

CORE served as the evaluation and technical assistance center for this initiative. CORE was part of the Health and Disabilities Working Group, a program of the Boston University School of Public Health. CORE conducted the multi-site evaluation and provided each demonstration project with program support and technical assistance. CORE also led the preparation and dissemination of the findings through reports, journal articles, community forums and conference presentations.

Journal Articles

Outlaw A, Naar-King S, Green-Jones M, Wright K, Condon K, Sherry L, & Janisse H. Brief Report: Predictors of Optimal HIV Appointment Adherence in Minority Youth: A Prospective Study. Journal of Pediatric Psychology, October 2010; 35 (9): 1011-1015. PubMed Abstract

Naar-King S, Outlaw A, Green-Jones M, Wright K, & Parsons JT. Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care. AIDS Care, July 2009; 21 (7): 868-873. PubMed Abstract

Rajabiun S, Rumptz MH, Felizzola J, Frye A, Relf M, Yu G, & Cunningham WE. The Impact of Acculturation on Latinos’ Perceived Barriers to HIV Primary Care. Ethnicity & Disease, Autumn 2008; 18 (4): 403-408. PubMed Abstract

Drainoni ML, Rajabiun S, Rumptz M, Welles SL, Relf M, Rebholz C, Holmes L, Dyl A, Lovejoy T, Dekker D, & Frye A. Health literacy of HIV-infected individuals enrolled in an outreach intervention: Results of a cross-site analysis. Journal of Health Communication, April-May 2008; 13 (3): 287-302. PubMed Abstract

Sacajiu G, Fox A, Ramos M, Sohler N, Heller D, & Cunningham C. The evolution of HIV illness representation among marginally housed persons. AIDS Care, April 2007; 19 (4): 539-545. PubMed Abstract

Tobias C, Cunningham WE, Cunningham CO, & Pounds MB. Making the Connection: The Importance of Engagement and Retention in HIV Medical Care. AIDS Patient Care & STDs, 2007; (Supplement 1): S3-S8. PubMed Abstract

Rajabiun S, Cabral H, Tobias C, & Relf M. Program Design and Evaluation Strategies for the Special Projects of National Significance Outreach Initiative. AIDS Patient Care & STDs, 2007; (Supplement 1): S9-S19. PubMed Abstract

Rajabiun S, Mallinson RK, McCoy K, Coleman S, Drainoni ML, Rebholz C, & Holbert T. “Getting Me Back on Track”: The Role of Outreach Interventions in Engaging and Retaining People Living with HIV/AIDS in Medical Care. AIDS Patient Care & STDs, 2007; (Supplement 1): S20-S29. PubMed Abstract

Rumptz MH, Tobias C, Rajabiun S, Bradford J, Cabral H, Young R, & Cunningham WE. Factors Associated with Engaging Socially Marginalized HIV-Positive Persons in Primary Care. AIDS Patient Care & STDs, 2007; (Supplement 1): S30-S39. PubMed Abstract

Naar-King S, Bradford J, Coleman S, Green-Jones M, Cabral H., & Tobias C. Retention in Care of Persons Newly Diagnosed with HIV: Outcomes of the Outreach Initiative. AIDS Patient Care & STDs, 2007; (Supplement 1): S40-S48. PubMed Abstract

Bradford J, Coleman S, & Cunningham W. HIV System Navigation: An Emerging Model To Improve HIV Care Access. AIDS Patient Care & STDs, 2007; (Supplement 1): S49-S58. PubMed Abstract

Cabral HJ, Tobias C, Rajabiun S, Sohler N, Cunningham C, Wong M, & Cunningham W. Outreach Program Contacts: Do They Increase the Likelihood of Engagement and Retention in HIV Primary Care for Hard-to-Reach Patients? AIDS Patient Care & STDs, 2007; (Supplement 1): S59-S67. PubMed Abstract

Sohler NL, Wong MD, Cunningham WE, Cabral H, Drainoni ML, Cunningham CO. Type and Pattern of Illicit Drug Use and Access to Health Care Services for HIV-Infected People. AIDS Patient Care & STDs, 2007; (Supplement 1): S68-S76. PubMed Abstract

Mallinson RK, Rajabiun S, & Coleman S. The Provider Role in Client Engagement in HIV Care. AIDS Patient Care & STDs, 2007; (Supplement 1): S77-S84.  PubMed Abstract

Bradford, J. The promise of Outreach for Engaging and Retaining Out of Care Persons in HIV Treatment. AIDS Patient Care & STDs, 2007; (Supplement 1): S85-S91. PubMed Abstract

Wong MD, Sarkisian CA, Davis C, Kinsler J, & Cunningham WE. The Association between Life Chaos, Health Care Use, and Health Status among HIV-infected Persons. Journal of General Internal Medicine, September 2007; 22 (9): 1286-1291. PubMed Abstract

Coleman S, Boehmer U, Kanaya F, Grasso C, Tan J, & Bradford J. Retention Challenges for a Community-Based HIV Primary Care Clinic and Implications for Intervention. AIDS Patient Care & STDs, September 2007; 21 (9): 691-701. PubMed Abstract

Kinsler JJ, Wong MD, Sayles JN, Davis C, & Cunningham WE. The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population. AIDS Patient Care & STDs, August 2007; 21, (8): 584-592. PubMed Abstract

Tobias C, Cunningham W, Cabral H, Cunningham CO, Eldred L, Naar-King S, Bradford J, Sohler NL, Wong MD, & Drainoni ML. Living with HIV But Without Medical Care: Barriers to Engagement. AIDS Patient Care & STDs, June 2007; 21 (6): 426-434. PubMed Abstract

Andersen M, Hockman E, Smereck G, Tinsley J, Milfort D, Wilcox R, Smith T, Connelly C, Adams L, & Thomas R. Retaining women in HIV medical care. Journal of the Association of Nurses in AIDS Care, May-June 2007; 18 (3): 33-41. PubMed Abstract

Cunningham CO, Sohler NL, Wong MD, Relf M, Cunningham W, Drainoni ML, Bradford J, Pounds MB, & Cabral HD. Utilization of Health Care Services in Hard-to-Reach Marginalized HIV-Infected Individuals. AIDS Patient Care & STDs, March 2007; 21, (3): 177-186. PubMed Abstract

Naar-King S, Green M, Wright K, Outlaw A, Wang B, & Liu H. Ancillary services and retention of youth in HIV care. AIDS Care, February 2007; 19 (2): 248-251. PubMed Abstract

Cunningham WE, Sohler NL, Tobias C, Drainoni ML, Bradford J, Davis C, Cabral HJ, Cunningham CO, Eldred L, & Wong MD. Health Services Utilization for People with HIV Infection – Comparison of a Population Targeted for Outreach with the US Population in Care. Medical Care, November 2006; 44 (11): 1038-1047. PubMed Abstract

Cunningham CO, Sohler NL, McCoy K, Heller D, & Selwyn PA. Health Care Access and Utilization Patterns in Unstably Housed HIV-Infected Individuals in New York City. AIDS Patient Care & STDs, October 2005; 19 (10): 690-695. PubMed Abstract

Mallinson RK, Relf MV, Dekker D, Dolan K, Darcy A, & Ford A. Maintaining Normalcy: A Grounded Theory of Engaging in HIV-oriented Primary Medical Care. Advances in Nursing Science, July-September 2005; 28(3): 265-277. PubMed Abstract


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