Andersen (2005)[57] Well-Being Nursing Intervention Detroit, Michigan N = 75 (38 in intervention and 37 in comparison) Demographics not reported but study focused on women with co-occurring mental health and substance abuse diagnosis RCT

(1)

Table, Appendix C (Supplementary Digital Content) - Study and Intervention Characteristics, Definitions (n= 42 interventions/39 studies) Primary author

Intervention name

Study Location Sample size Target Population Demographics

Study Design

&

Quality

Intervention Deliverer and Strategies

Comparison Deliverer and Strategies

Out of Care Definition

Outcome Definition(s)

Andersen (2005)^[57]

Well-Being Nursing Intervention

Detroit, Michigan N = 75 (38 in intervention and 37 in comparison) Demographics not reported but study focused on women with co- occurring mental health and substance abuse diagnosis

RCT^a Weak

Nurse

• Outreach

• Help with making and keeping appointments with care providers for HIV, mental illness, and substance abuse

• Help with connecting to case managers

• Help with payment authorizations for health care from health care payers

• Transportation

• Appointment accompaniment

Care as usual (deliverer and strategies not specified)

Missed an appointment in last 4 months

Retention: Mean # of visits at 3 months

(2)

Andersen M (2007) ^[13]

Transportation

& LIGHT

Detroit, MI N = 61

(Transportation only)

N = 51

(Transportation Plus)

Urban HIV- positive women who were loosely connected to HIV medical care 100% Female 91% Black 6% White 3% Multiracial and other Mean age = 45 years

Non RCT One-group pre/post Weak

Nurse

Transportation Only

• Transportation to HIV medical appointments Transportation Plus LIGHT

• Transportation

• Home visit

• Counseling

• Referrals to drug treatment

NA^b More than 4

months without an HIV-related medical appointment;

reported having problems keeping HIV- related medical appointments;

reported missing one or more HIV- related medical appts in the past year;

reported having no scheduled HIV-related medical appt.

Retention: Kept medical

appointments (self report and face-to- face interviews and chart reviews)

(3)

Anderson, S.

(2020)^[36]

Louisiana Links (LA Links)

New Orleans, Baton Rouge, and Shreveport, Louisiana N = 5,714 (3,038 in intervention, 2,676 in

comparison) 67.9% Male 30.8% Female 1.3% Transgender 72.1% Black 23.6% White 4.3% Other 2.9%

Hispanic/Latino Mean age = 43.1

Non RCT Historical comparison Weak

Linkage-to-care coordinator

• Data-to-Care

• Guides through re-engagement process

• Provides treatment adherence counseling

• Refers to support and prevention services Above services provided in addition to usual care services (see comparison)

Disease intervention

specialists from the Louisiana Office of Public Health STD/HIV Program Care-as-usual services included:

• Case

management

• Dental care

• Direct emergency financial assistance

• Housing assistance

• Medication assistance

• Mental health therapy and counseling

• Nutrition services

• Outreach

• Substance abuse

treatment and counseling

• Transportation assistance

Experiencing a 12-month gap between recorded CD4 T- cell or VL tests

Re-engagement:

receiving a CD4 or VL test in a study period after being

categorized as previously diagnosed and not in care in that same study period

(4)

Asamsama, O.

(2017). ^[21]

HIV Nurse Navigation

Washington DC.

N= 84 98% Male 86% Black 4% White 1% Hispanic 9% Other Mean age = 56 years

Non RCT One-group pre/post Moderate

Nurse Navigator

• Case

management

• Outreach

• Collaboration with existing support systems

• Medication adherence and clinic

engagement support

• Pillbox renewals

• Appointment and medication renewal reminders

• Same-day appointments

• Maintained client database to disseminate pertinent info about clients (e.g., moved out of state) to treatment team

NA Poorly engaged:

either multiple or no shows for scheduled appointments, inconsistent medication renewal, and/or elevated viral loads.

Retention: Number of scheduled clinic visits

Viral suppression:

< 200 copies/mL

(5)

Avoundjian, T.

(2020) ^[37]

Real-time data exchange

Seattle, Washington N = 518 (242 received

intervention and 276 in historical cohort)

81% Male 17% Female 2% Transgender 44% White 32% Black 13%

Hispanic/Latinx 11% Other 13% 19-29 years 26% 30-39 years 31% 40-49 years 30% ≥ 50 years

Non RCT Historical Comparison Moderate

HIV care relinkage team (Health Department (HD) Staff comprising disease intervention specialists with expertise in providing HIV care engagement assistance)

• Alert sent to relinkage team when a PWH with viral load ≥ 200 copies mL is seen in

emergency room or admitted as an inpatient

• Relinkage team attempts to meet PWH in person to discuss care re- engagement, identify barriers to care, assist with making follow-up appointment, and link patients to supportive services

NA Previous

positive HIV laboratory test and most recent VL test ≥ 200 copies mL and seen at emergency department or admitted as an inpatient at one of three

University of Washington hospitals

Re-engagement: viral load test ≤ 3 months after an eligible ED visit/in-patient admission

Viral Suppression:

viral load < 200 copies mL in the 6 months after an eligible visit

(6)

Bove, J. (2015)

[44]

Clinic-based, surveillance informed patient retracing

Madison, Wisconsin N=1399 (753 received

intervention and 646 in historical cohort)

84% Male 16% Female 60% White 21% Black 12% Hispanic 1% Multiracial 4% Native American 14% Missing 9% < 30 years 23% 30-39 years 35% 40-49 years 33% ≥ 50 years

Non RCT Historical Comparison Moderate

Clinic data manager Linkage Specialist

• Data to care

• Appointment scheduling help

• Works with patient, case manager, medical provider, and clinic staff to schedule a follow-up appointment.

• Appointment reminders

• Follow up whether the linkage appointment was kept

• Hospital, home or field visits

• Transportation

Deliverer not specified Strategies not specified

No visit a visit for over 12 months

Re-engagement:

time between the date of identification as out-of-care and the date of the first completed medical visit

Retention: >2 visits

>3 months apart in 12 months

Viral suppression:

< 200 copies/mL

(7)

Bradford, J.

(2007)^[15]

Patient Navigation

Portland OR, Seattle WA, Boston MA, Washington DC N = 437

77% Male 23% Female 44% Black 23% Hispanic Age not reported

Patient Navigator

• Skills building for interactions with health care providers

• Provide emotional support

• Navigation of health and social service systems

• Appointment coordination

• Education

• Provide concrete services (e.g., bus tokens, childcare

assistance, food vouchers, furniture, emergency financial assistance, clothing)

• Referrals

NA Not fully

engaged in HIV primary medical care or at risk of falling out of care

Care engagement:

No HIV care within 6 months

Retention: 2 or more HIV care visits in last 6 months

Viral suppression:

Undetectable viral load (threshold not reported)

(8)

Christopoulos, K.

(2018)^[62]

Connect4Care (C4C)

San Francisco, CA N= 230 (116 in intervention and 114 in

comparison) 83% Male^c 13% Female 4% Transgender (male to female) 35% White 31% Black 21% Latino 13% API/mixed 49% MSM

33% heterosexual 18% bisexual Mean age = 45

RCT Moderate

Deliverer not specified

• Appointment reminders (text)

• Motivational, informational, and supportive text messages 3 times per week over a period of one year

Deliverer not specified Appointment reminders (text)

In care for greater or equal to 12 months with either 1 visit or more missed visits or lack of 6 month visit constancy

Retention:

Visit adherence - number of medical visits kept among the number scheduled, excluding cancelled or rescheduled appts*

Visit constancy - calculated kept visit percentages within each 6-month study period*

*Stratified results (excluding newly diagnosis) from article, Table 2 (N=197)

Viral suppression:

< 200 copies/mL**

** Data obtained from author on OOC (N=140)

(9)

Corado, K.

(2018)^[58]

ALERT Active Linkage Engage Retention Treatment

Southern California N = 116 (60 in intervention, 56 in comparison)

Persons new to care or lost to care

93% Male 6% Female .9% Transgender (male to female) 73% White 9% Black 3% Asian 4% Multiracial 12% Other 66% Hispanic Mean age = 38

RCT Moderate

Health Coaches

• Coaching sessions on HIV health literacy, navigating health care system, disclosure, adherence, and self-efficacy

• Made calls to follow up on missed

appointments

• Ap

• Fovisits

• Outreach and retention activity according to ongoing clinic standards

Not having a clinic visit for at least 180 days and a

detectable HIV RNA

Re-engagement:

Returned to care^**

(10)

Dillingham, R.

(2018) ^[46]

PositiveLinks (mobile health intervention)

Central Virginia N = 60**

64% Male 33% Female 3% Transgender MTF

30% White 57% Black 8% Hispanic 2% Asian 3% Multiracial Age not reported

Phone App

• Custom smart phone app that was developed with patients at the Ryan White Clinic

• App included educational resources, daily queries of stress, mood, and medication adherence;

weekly quizzes, appointment reminders, and a community message board

NA Returning to

care after a lapse or at risk of falling out of care as

determined by their care provider.

Retention:

HRSA: 2 kept appointments with an HIV care provider that were separated by 90 days within a 1- year period

Visit constancy:

proportion of 4- month time intervals in which 1 visit with an HIV care provider was completed in a 1-year time period Viral suppression:

< 200 copies mL

(11)

Dombrowski, J.

(2018) ^[45]

Data to Care

Washington State N = 997

87% Male 13% Female 16% Black 43% White 9% Hispanic 3% Asian/Pacific Islander

< 1% American Indian/Native American 29% Multiple races and missing 8% < 30 years 24% 30-39 years 38% 40-49 years 29% 50+ years

Non-RCT Stepped wedge, cluster randomized Moderate

Disease Intervention specialists

• Data to care

• Identify barriers to care and treatment

• Develop plan to address

identified barriers

• Counseling (in clinic or field) and over phone

• Share pertinent info to medical provider and case manager

• Follow up to assess whether patient had seen their medical provider and offer help

NA 12-month gap

in lab reports or recent

unsuppressed VL

Re-engagement: had a viral load test within 12 months Viral suppression:

< 200 copies mL

(12)

Dombrowski J.

(2019) ^[38]

Max Clinic

Seattle, Washington N = 150 (50 intervention patients; 100 control patients) 71% Male 26% Female 3% Transgender, gender queer or nonbinary 47% White 32% Black 3% Asian or Pacific Islander 3% American Indian or Alaska Native

9% Multiple Mean age = 43

Non-RCT Non-

randomized comparison Weak

Non-medical case manager who is a public health disease intervention specialist who specialize in HIV care engagement Medical case manager – Master’s-level social workers with HIV-specific

training

• Walk in access to medical care 5 afternoons a week

• Walk in access to case

management 5 days a week

• Text message and direct phone access to case managers

• Care

coordination, navigation, and

Madison Clinic patients identified retrospectively who met eligibility for Max Clinic but did not enroll.

Madison Clinic is a comprehensive HIV primary care clinic with on-site medical case management and pharmacy located in a separate building on the same campus as the Max Clinic

Not taking antiretroviral therapy or virally

unsuppressed at the time of last viral load measurement (≥ 200 copies mL); poorly engaged in HIV care (multiple no-shows or no visits in the past year); and failed to re-engage in care after outreach attempts from the clinic or health department

Retention:

completing ≥ 2 visits with a medical provider ≥ 60 days apart

Viral suppression: ≥ 1 VL result < 200 copies/mL at any time during the 12- month analysis period

Continuous viral suppression: ≥ 2 consecutive

suppressed VL results

≥ 60 days apart aRRR = 1.5, 95% CI:

0.5 – 5.2

(13)

support (two levels: 1) intensified (case managers serve as

primary contacts for patients, providers, and for

coordination between Max Clinic and other agencies and 2) transitional – staff receive automated alerts when patients are seen in the emergency room or

admitted to the hospital in the University of Washington medical system

• Max Clinic staff work with inpatient medical teams to plan

transition to

(14)

outpatient care and day-of- discharge Max Clinic visit

• Incentives (food vouchers, snacks,

transportation help, cash for visits and viral suppression

Donovan, J.

(2018) ^[47]

NC-LINK (linked to SBC services – Fadul; but clinic/”low touch”

intervention.

North Carolina N = 717 (located patients who were presumed to be out of care) 70% Male

29% Female 1% Gender non- conforming 70% Black 25% White 3% Hispanic 3%

Other/multiple

Patient navigators or case managers

• Data to care (non-

surveillance based)

• Phone calls to reach and reschedule patients

NA Did not receive

HIV medical care from the clinic within the past 6- 9 months and had no known future

appointment scheduled with an HIV provider

Viral suppression:

< 200 copies per mL

(15)

40% 18-29 years 31% 30-39 years 21% 40-49 years 7% ≥ 50 years

Enriquez, M.

(2019)^[59]

Peers Keep it Real

A metropolitan area (city/state not specified) N = 30 (20 received

intervention; 10 were wait-listed) 57% Male

37% Female 6% Transgender 67% Black 7%

Hispanic/Latino 23% White 3% Other

RCT Weak

Peer interventionist Nurse

• Identify barriers to engagement in care,

medication adherence, and sustained viral suppression

• Develop tailored strategies based on

identified needs

Wait list control Documentation of nonadherence to ART and/or being out of medical care > 6 months

Viral suppression (<200 copies) (proxy for medication adherence in study):

(16)

3% 18-24 years 20% 25-34 years 23% 35-44 years 53% 45-54 years 0% 55+ years

• Peers served as role models who provided positive reinforcement to help

participants create practical plans to reach desired health outcomes

• Knowledge and skills building

Fadul, N. (2019)

[14]

Linked to NC- LINK, but

focused on State Public Health Bridge Counselor (SBC) services

North Carolina

N=264 (77 received SBC, 187 did not receive SBC)

70% Male 30% Female

74% Black 20% White 6% Other

30% 18-25 years 35% 26-35 years 25% 36-45 years 10% 46+ years

Non-RCT Non-

State Public Health Bridge Counselor (SBC)

• Identify barriers to care and provide assistance to address barriers

• Strengths-based case

management

• Referrals to substance abuse treatment centers and behavioral health services

Deliverer not specified No SBC services

Did not receive HIV medical care from the clinic within the past 6- 9 months

Re-engagement:

Completed a HIV primary care visit in a 6-month period

Viral suppression:

< 200 copies per mL

(17)

• Transportation assistance

• Tracking using multiple

surveillance data- bases and home visits

Flash, C. (2015)

[48]

Routine Universal Screening for HIV (RUSH)

Houston, Texas

N = 2,068

65% Male 35% Female

68% Black 17% Hispanic 13% White 2% Other

4% 16-24 years 19% 25-34 years 32% 35-44 years 32% 45-54 years 13% 55+ years

Non RCT One-group pre/post Moderate

Service Linkage Workers (SLW)

• Opt-out HIV testing

• Case

management

• HIV posttest counseling

• Transportation

• Help with paper work for agency and Ryan White eligibility determination processes and AIDS Drug Assistance

NA Persons who

were diagnosed with HIV at least 1-year prior who had an

emergency room visit between 2009 and 2012 and a positive HIV test at the visit

Care engagement:

Completed a HIV primary care visit in a 6-month period

Retention:

HRSA definition: 2 HIV primary care visits in a 12-month period with 2 visits being at least 3 months apart

Viral suppression:

< 200 copies/mL

(18)

Program applications

• Appointment scheduling help

• Follow-up for missed appointment

Gardner, L.

(2014) ^[63]

Enhanced

Personal Contact

Boston, MA;

Brooklyn, NY;

Baltimore, MD;

Birmingham, AL;

Miami, FL;

Houston, TX N= 1312 (1225 in intervention, 613 in comparison) 63% Male^d 36% Female 1% Transgender 68% Black 16% Hispanic 13% White

RCT Moderate

Trained

Interventionists Enhanced Contact

• Establish rapport and maintain contact with patients

• Positive

affirmations to reinforce importance of attending medical appointments

• Appointment reminder calls

• Missed visit call

Clinic staff

Appointment reminders (automated or made by clinic staff)

Missed one or more visits in the past 12 months, had a gap in care of at least 6 months in the previous year

Retention in care:*

Completing at least 1 primary care visit between 1 and 30 days after hospital discharge and at least 1 subsequent

primary care visit between 31 and 180 days after discharge

*stratified results (excluding newly diagnosis) from article, Table 4 (N=1312)

(19)

3% Other

11% 18-29 years 20% 30-39 years 34% 40-49 years 29% 50-59 years 7% ≥ 60 years

• Skills building on

communication with providers, personal organization, and problem solving

• Develop plan to address needs and tap into strengths Giordano, T.

(2016) ^[60]

Mentor Approach for Promoting Self- care (MAPPS) Based on IMB model

Houston, TX N= 460 (202 in intervention, 215 in comparison) 72% Male 28% Female 65% Black 22% Hispanic 13% White 13% < 30 years 26% 30-39 years 35% 40-49 years 25% ≥50 years

RCT Moderate

Peer Mentors

• Mentors serving as role models for managing HIV and

encouraging active self- management

• Brochures on navigating the HIV care

system, options for care, and impact of medications all focused on importance of obtaining

Based on Project Respect and provided

instruction on safer sex and safer drug use

No HIV clinic visit for at least 3 of the 4 previous quarter-years and not having had at least 3 consecutive HIV VL results over at least 6 months

Retention:

Completing at least 1 primary care visit between 1 and 30 days after hospital discharge and at least 1 subsequent

primary care visit between 31 and 180 days after discharge Viral suppression: <

400 copies/mL

(20)

outpatient medical care

• Mentors shared personal stories

• Identify barriers and facilitators to outpatient care, followed by goal setting and action planning to increase care.

Hart-Malloy, R.

(2018) ^[32]

Data to Care (D2C)

New York State

N=348 (19 received Combined D2C Model, 348 received Health Department Model)

Demographic info not reported

Non-RCT Non-

randomized comparison Moderate

Health Department Partner Services staff

Field workers

• Data to Care

• Field workers work with community health centers to assist in investigation processes through case conferencing

Health Department Partner Services staff

Data to care

No HIV-specific lab results reported in a specific time frame (9 months in New York City and 13-24 months in rest of the state)

Re-engagement:

having a confirmed follow up HIV medical appointment

(21)

Kral, A. (2018)

[39]

Project Bridge Oakland

Oakland, California

N = 48 (19 in intervention and 29 in comparison)

Persons who use drugs

68% Male 21% Female 11% Transgender

79% Black 5% Latino/Latina 5% White 11% Other

Non RCT Non-

randomized comparison group Weak

Social worker HIV physician

• Strengths-based case

management

• Case conference

• Outreach

No services provided since they were already in HIV care

Not having seen a medical doctor for HIV care in the past 3 months; not having a forthcoming scheduled appointment with an HIV provider, or not currently taking HIV medications

Viral suppression:

< 200 copies/mL

Lubelchek, R.

(2016) ^[18]

Real-Time Alerts

Chicago, IL

N=55 (35 received intervention, 20 could not be contacted)

73% Males

78% Black 12% Hispanic

Average age= 45

Non RCT Non-

Project Coordinator

• Real-time text message alert system to notify program staff when lost to care patients

registered for non-primary care visits

• Help with scheduling appointments

Patients who could not be contacted by project coordinator

No primary care visit in 7 or more months

Re-engagement:

Attended primary care appointment within 3 months of alert

Viral suppression:

Undetectable viral load (threshold not reported)

(22)

• Contact with patient during medical visit Coordinator also called if could not meet in person

Magnus, M.

(2012) ^[33]

Data to Care

Louisiana N = 996 (LaPHIE = 419, in-care

comparisons = 577;

data from 344 LaPHIE participants were used for the analysis^e

LaPHIE^f 63% Male 37% Female

68% Black

32% White/Other

46% <35 years 54% ≥35 years

In-Care^g 48% Male 51% Female

89% Black

11% White/Other

34% <35 years 66% ≥35 years

Non RCT Non-

Public Health

Informatics Exchange Emergency Room Providers

• Linking of statewide public health

surveillance data with patient-level emergency room (ER) data

• Automated alert to ER providers who are provided clinical decision support to engage out-of- care persons back into care

Time-matched random sample of persons with HIV who had been seen for HIV care within the system at least once within the past 5 years who had previously

experienced delayed entry into care of > 1 year following diagnosis or had at least 1 prior break of

> 1 year in care

No CD4 or VL monitoring for 1 year or more

HIV Viral Load:

VL > 10,000 RNA copies/mL

(23)

Maulsby, C.

(2018) ^[56]

Access to Care (A2C)

AIDS Action Committee

Boston, MA

N = 294

Demographics not reported

Advocacy teams consisting of HIV peer advocate, medical case manager, and other staff

• HIV care coordination with focus on economic stability

NA Out-of-care:

failed to meet the Health Resources Services Administration (HRSA) HIV/AIDS Bureau definition of retention (two visits per year at least 60 days apart)

The Boston site also included those at risk for falling out of care (e.g., active substance use, mental health issues)

Viral suppression:

Not defined

Maulsby, C.

(2018) ^[56]

Chicago, IL

N = 537

Non RCT Peer navigators Case managers

NA Out-of-care:

failed to meet the Health

Viral suppression:

Not defined

(24)

AIDS Foundation Chicago

One-group pre/post Weak

Systems and individual level intervention that works through a network of AIDS service organizations to support

continuous HIV medical and social supportive services

Resources Services Administration (HRSA) HIV/AIDS Bureau definition of retention (two visits per year at least 60 days apart)

Maulsby, C.

(2018) ^[56]

St Louis Effort for AIDS

St. Louis, MO

N = 295

Care team (peer advocate, nurse, and case manager)

Eliminate barriers to care and support engagement in HIV care

NA Out-of-care:

failed to meet the Health Resources Services Administration (HRSA) HIV/AIDS Bureau definition of retention (two visits per year at least 60 days apart)

Viral suppression:

Not defined

Messeri, P.

(2020) ^[40]

ACCESS New York

New York City, New York N = 525 (476 were not

assigned patient navigator before first medical visit and 49 were assigned patient navigator after

Non-RCT Non-

Patient navigators with peer and professional qualifications:

community health outreach workers (CHOWs) who are PWH (peers) and health navigators (HNs) who have a bachelor’s degree

Patients not assigned to a patient

navigator.

AC members who had no HIV primary care visit for at least 6 months at the time of study enrollment

Re-engagement:

number of days elapsed between enrollment in

intervention and first post-enrollment HIV primary care visit

Retention:

Number of days between the date of

(25)

first medical visit) Demographics are from 476

patients.

Amida Care (AC), (a New York City Medicaid HIV Health Plan) members 68% Male 49% Black 20% Hispanic 5% White 26% Other or unknown Mean age = 43 years

and experience in working with PWH

•

• Appointment help

• Education

• Needs assessments

• Developed care plans and assisted in care plan

implementation

• Outreach

• Facilitated transportation

• Helped clients fill medication prescriptions, connect to case management, and receive lab work

• Followed up with service providers

the first post ACCESS NY primary care visit and the date of the medical visit prior to a first 190-laps between successive visits

(26)

Plimpton, E.

(2020) ^[49]

Quality Improvement Project

Dallas, Texas N = 22

100% Female 64% Black 4% Hispanic 32% White 41% 18-39 years 55% 40-59 years 4% 60+ years

Non-RCT One group pre-post Weak

Medical case managers who were registered nurses Health care providers Medical assistants Front desk staff

• On-site education to facilitate enrollment into patient portal system

•

NA Women with HIV

at risk of disengaging in care, defined as newly entering care, re-engaging in care after a lapse ≥ 1 year, or having a clinic acuity score of 1- 4.

Retention:

Number of missed appointments

Robbins, G.

(2012) ^[19]

Fasttrack

Boston, MA

N=1,011 (506 in intervention, 505 in comparison)

78% Male 22% Female

54% White 22% Black 12% Hispanic 12% Other 75% >40 years

RCT Strong

• Alert messages to providers through their electronic medical record (EMR) home page, patient- specific EMR, and biweekly emails that provide key clinical

information and a streamlined mechanism for providers to request follow- up

Static alerts which were only visible on patient-specific EMR and provided no additional information or semi-automated scheduling mechanism.

Patients with missed appointment and no subsequent arrived appointment within 7 days;

no arrived appointment in previous 4 months and no scheduled appointment in the next 12 months and high risk patients who

Retention: Attending an appointment within 6 months

(27)

appointments and lab tests

missed

appointments in the previous year, no arrived appointment in previous

months, and no scheduled appointment in the next 2 months

Robertson, M.

(2019) ^[16]

HIV Care Coordination Program (CCP)

New York City, NY

N* = 326 (178 received CCP, 148 did not)

*info from author

67% Male 33% Female

5% <=24 years 52% 25-44 41% 45-64

Non-RCT Non-

Care Coordinator, Medical Center Liaison, Patient Navigator, Medical Care Provider

• Outreach

• Case

management

• Multidisciplinary care team communication and decision making via case conferences

• Patient navigation

Persons with HIV who met CCP eligibility criteria but did not receive CCP services were identified using surveillance data

No viral load events for >12 months

Retention:

HRSA definition - Having at least 2 lab tests (CD4 or VL) dated at least 90 days apart with at least 1 of those tests in each half of a given 12-month review period

Viral Suppression:

≤ 200 copies/mL

(28)

2% 65+ • ART adherence support

• Structured health promotion using a curriculum

• Saafir-Callaway,

B. (2020) ^[34]

Recapture Blitz (RB)

Washington, DC

N = 103 (57

received RB, 46 did not)

68% Male 20% Female 12% Missing

78% Black 4% Hispanic 5% White 12% Missing

16% 20-29 years 25% 30-39 years 24% 40-49 years 16% 50-59 years 7% ≥ 60 years

Non-RCT Non-

Ryan White CARE Act-funded primary care providers

• Data to Care

Persons who were not re-engaged during RB and were matched in the HIV surveillance system to determine if they re-engaged in care on their own

No evidence of a viral load result, CD4 result, or care visit in the past 6-12 months

Re-engagement:

At least one CD4 or VL test result during the 6, 12, and 18 months post RB Viral Suppression:

<200 copies/mL

Sachdev, D.

(2020) ^[50]

Linkage, Integration, Navigation and

San Francisco, California

N = 233

85% Male 9% Female

Non RCT, One group pre-post Weak

Patient navigators

• Data-to-Care

• Warm handoff to long term case manager for

NA VL > 1500

copies/mL within last 4 months or no VL in > 15 months per eHARS (Enhanced

Retention in HIV care Having 2 tests (viral load, CD4, or

genotype) at least 90 days apart in the 12 months before LINCS enrollment (pre-

(29)

Comprehensive Services (LINCS)

6% Trans Female

27% Black 28% Latinx 37% White 8% Other

ongoing support as needed

• Benefits navigation

• Clinic

accompaniment

• Motivational interviewing

• Modified strengths-based case

management

HIV/AIDS Reporting System)

LINCS retention) and in the 12 months after assignment closure date (post- LINCS retention) Viral suppression:

Having at least 1 viral

< 200 copies/mL at any time within the 12 months before LINCS enrollment or after LINCS closure.

Shacham, E.

(2018) ^[51]

Barrier

Elimination and Care Navigation (BEACON) Project

St. Louis, Missouri

N=322

78% Male 20% Female 2% Transgender 76% Black 24% White Mean age = 37

Non RCT One-group, pre/post Weak

Community HIV nurse

Peer navigator

• Intensive case management

• Emergency stabilization funding to address basic needs (e.g., rent, security deposits, transportation costs)

NA Not in medical

care for 12 months or longer and

documentation of having an HIV infection

Viral suppression:

< 200 copies/mL

Undetectable viral loads: < 20 copies/mL

(30)

Shade, S. (2015)

[52]

Health Information Technology

Not specified

N = 100

84% Black 16% White

Mean age = 40

Non RCT One-group, pre-post Weak

Alert system

• Data to care

• Alert system that notifies providers that OOC PWH shows up for care at an

emergency room

NA Not ever

received a CD4 or viral load test or had not received one in at least the past year

Re-engagement:

at least one medical visit or at least one lab test CD4 or viral load during a 6- month period Viral suppression:

< 75 copies/mL

Sharp, J. (2019)

[41]

Health Information Exchange

Atlanta, Georgia

N = 98 (20 received social work services and 78 did not)

Demographics reflect those who received social work services (n=20)

93% Black 6% non-Black

70% Male

Mean age = 41 years

Non-RCT Non-

Social workers

• Data-to-care

• Alerts

• Education

• Assesses barriers to care

• Co-located services

• Open

appointment

• Telephone calls to encourage patient to return to care

Patients who generated an alert but were not contacted by the social worker in the emergency

department or admitted to the hospital

No CD4 or HIV-1 RNA tests during the last 14 months

Re-engagement:

Any visit with an HIV provider within the health system or any CD4 or HIV RNA result within the health department database during the 6-month follow up period

Viral suppression:

VL < 200 copies/mL during the 6-month follow up period

(31)

Smith, L. (2018)

[61]

60 Minutes for Health

Bronx, NY N = 16 (8 in intervention, 8 in comparison) 63% Female 37% Male 63% Black 37% Hispanic Mean age = 49

RCT Strong

Health Educator

• Reviewed medical charts to identify poorly retained patients

• Illustrated workbook

• Content focused on physical and emotional health,

understanding one’s HIV care history, and achieving personal health goals

Health Educator

• Illustrated workbook

• Content

focused on diet and nutrition

Having a gap in care more than or equal to 6 months over the previous 18 months

Retention: # of quarters with a documented visit HRSA definition - Having at least 2 lab tests (CD4 or VL) dated at least 90 days apart with at least 1 of those tests in each half of a given 12-month review period

(32)

Sohail, M. (2019)

[43]

Data for Care (D4C) Alabama

Alabama N = 3859 (Total number of unique participants;

number of participants by risk group were not reported)^j 76% Male 23% Female 1% Transgender persons

65% Black 32% White 3% Other Median age = 46 years for

intervention group, 47 for comparison

Non RCT Non-

Front desk staff Social worker Linkage and retention coordinator

• Follow-up calls when

appointments were missed

• Enhanced personal reminder calls for persons considered moderate and high risk for missing

appointments

• Help with transportation, food assistance, and housing for persons

considered moderate and high risk for missing

appointments

No D4C services Missed 1 or more visits within study period

Retention:

Proportion of missed visits

(33)

Tesoriero, J.

(2017) ^[35]

Expanded Partner Services Data to Care

New York State

N=233 (166 received

intervention, 67 did not)

61% Male 38% Female 1% Transgender 50% Black 26% White 13% Hispanic 9% Other 2% Unknown 16% 20-29 years 22% 30-39 years 27% 40-49 years 28% 50-59 years 7% >60 years

Non-RCT Non-

Expanded Partner Services (ExPS) Advocates

• Data to Care

• Maximized medical provider participation

• Located patients out of care

• Prioritized cases for fieldwork

• Screened for behavioral risk factors

• Provided risk- reduction counseling

• Helped patients self-notify partners

Individuals

interviewed but not relinked to care by ExPS advocates

No prognostic or diagnostic lab results in the prior 13 to 24 months

Re-engagement:

Attending 1 or more HIV medical

appointments

Retention: having 2 or more HIV lab tests in the 6 months following case closure

Udeagu, C.

(2019) ^[42]

Enhanced data- to-care

New York City, New York

N = 3527 (184 received enhanced intervention, 3343 received routine data-to-care services)

Non-RCT Non-

Program managers Data analyst

Disease intervention specialists

Medical Director Clinic Administrator Patient navigator

• Enhanced data- to-care included

Program managers Data analyst

Disease intervention specialists

Medical Director Clinic Administrator Patient navigator

No HIV viral load or CD4 cell counts in New York surveillance registry for at least 9 months

Re-engagement:

Not specified how measured, but probably clinic visit verified with HIV- laboratory reports in registry post

scheduled clinic

(34)

Median age = 32 years for

intervention group;

31 for comparison

routine data-to- care activities but also added review of HIV clinic medical records and integrated roles for involved health

department and clinic staff

Routine data-to-care in non-participating clinics

appointments and or telephone calls with providers

Wohl, A. (2011)

[53]

Youth-focused case

management

Los Angeles, CA

N = 33

91% Male^h 3% Female 3% Transgender 3% Other/Refused

54% Black 46% Latino

Mean age = 21

Non-RCT One-group pre/post Weak

Paraprofessional, Bachelor-level case managers

• Psychosocial case management

• Treatment education &

adherence support

• HIV risk reduction counseling

NA Intermittent care

(less than 2 HIV primary care visits in the previous 6 months)

Retention in care:

Mean number of HIV care visits in past 6 months

Wohl, A. (2016)

[55]

Navigation Program

Los Angeles, CA

N = 78ⁱ

78% Male 18% Female

Navigator

(paraprofessional)

• Data-to-Care

• Modified ARTAS (strengths-based

NA No HIV care visits

in the previous 6- 12 months and last VL was > 200 copies per mL or

Viral Suppression: <

200 copies/mL

(35)

4% Transgender

71% Latino 18% Black 6% White 5% Multiracial or Other

case

management)

no HIV care visits in > 12 months

Zurlo, J. (2020)

[54]

OPT-In for Life

Harrisburg, Pennsylvania

N = 92

73% Male 25% Female 2% Transgender persons

43% Black 16% Hispanic, Latino or Latina 53% White 3% Other

10% 18-21 years 28% 22-25 years 33% 26-29 years 29% 30-34 years

Non RCT One-group pre-post Moderate

Opt-in-for-Life app HIV clinical care team (nurses, physicians, case managers) Administrative support team Social media content development team

The app allowed users to:

• View HIV viral loads and CD4 counts

• Send messages to care team

• Receive messages that helped patient to engage in care

NA Six month or

greater gap in HIV care (measured by seeing an HIV medical provider or completing a CD4 and/or HIV viral load test) within the past 24 months, or had a detectable HIV viral load (>

200 copies/mL)

Retention in care:

Having at least one HIV medical care visit in each 6-month period during the 18-month intervention

period, with a minimum of 60 days between visits.

Viral suppression:

(<200 copies/mL)

(36)

a Randomized controlled trial

b Not applicable

c Demographics reflect total sample characteristics which included newly diagnosed persons (n = 26)

d Demographics reflect total sample characteristics which included patients that were new based on patient’s first or second visit, or not seen in ≥ 3 years (n=526)

e Data from 344 LaPHIE participants who were identified during the first 18 months of the system’s implementation.

f Demographics reflect sample characteristics for Louisiana Public Health Information Exchange (LaPHIE) participants (n = 419)

g Demographics reflect sample characteristics for in-care comparisons (n = 577)

h Demographics reflect total sample characteristics which included new to care (n=27)

I Demographics reflect total sample characteristics which included never in care (n =2) and unstable in care (e.g., recently released from jail, prison, or other institution with no regular HIV medical provider (n = 25)

• Set up health goals

• Set reminders for taking

medications

• Support self- management of health status via reflection journal

• Have a virtual visit with HIV care team member(s)