Supporting HIV care through education and innovation

Topic: Engagement in Care

Engagement in HIV/AIDS care falls along a continuum, from not being in care at all to being fully engaged, with interim points that reflect less-than-consistent engagement in care. A significant proportion of people living with HIV/AIDS in the U.S. are not fully engaged in care (do not know their HIV status, inadequate antiretroviral therapy).

A wide array of interventions are used to enhance care engagement (e.g., HIV testing to help people learn their HIV status and enter care, motivational interviewing, street outreach, adherence support, case management to help clients navigate the health system, in-reach services within an HIV clinic like follow-up with patients). 

Training resources

  • Philadelphia Office of HIV Planning
    November 2012
    This interactive InfoGraphic explains the Treatment Cascade--a visual model that shows how the proportion of individuals living with HIV/AIDS with fully suppressed virus (i.e., those fully benefiting from HIV/AIDS therapy) cascades downward due to factors like not knowing one's HIV status or being in care inconsistently or not at all.
  • January 2014

    These presentations were prepared for the July 29-31 2013 Ryan White Program Part A reverse site visit.

  • Curriculum Manual Cover
    HRSA HIV/AIDS Bureau
    September 2013

    This curriculum is meant to inform implementation of a new jail linkage program and to assist organizations in expanding their current jail work.

  • HRSA Logo
    HRSA HIV/AIDS Bureau
    June 2013

    These presentations were prepared for the June 2013 Ryan White Program Part B reverse site visit.

  • HRSA HIV/AIDS Bureau
    January 2007

    Facilitator's training curriculum (and slides) for a two day session designed to educate service providers about strategies needed to address HIV/AIDS-related stigma in their communities. Five modules include participant training exercises. Accompanying slides also available for download.


Best practices


  • HRSA HIV/AIDS Bureau

    Quality improvement campaign to improve patient retention in HIV/AIDS care.



Training Resourcess

  • Training Manual Cover
    HRSA HIV/AIDS Bureau
    September 2013

    This training manual synthesizes lessons learned from the federally funded, innovative Special Projects of National Significance Enhancing Linkages to HIV Primary Care & Services in Jail Settings Initiative, otherwise known as EnhanceLink.

Slide sets

  • HRSA HIV/AIDS Bureau
    February 2013

    HRSA’s Continuum is a graphical depiction of the spectrum of circumstances for being in and out of HIV/AIDS care. At one end is unawareness of HIV status and not in care. At the other is being fully engaged in care.



  • HRSA HIV/AIDS Bureau
    August 2010

    Clinical debate of the mathematical theory that HIV/AIDS can be eliminated from society if all adults are tested regularly and all infected persons are put on antiretroviral therapy—regardless of CD4 level. 



    The Patient Satisfaction Survey is a short, easily administered questionnaire that provides health centers with information and insight on their patients' view of the services they provide.

  • National Minority AETC, September 2012

    BE SAFE is a framework that uses culturally pluralistic content and perspectives based on these six core elements: Barriers to Care, Ethics, Sensitivity of the Provider, Assessment, Facts, and Encounters.

Best practices


  • Oregon Health Authority
    Oregon Health Authority, October 2012

    Series of care plan forms to assess clients in terms of intake, assessment, and care. Forms include: intake, eligibility determination, residency verification, screening for care and psychological services, client rights and responsibilities, nursing assessment, and a care plan.

  • Iowa Department of Public Health, September 2011
    Tool for clients to use in recording weekly goals as part of their overall care plan to outline goals and objectives for HIV/AIDS care.
  • Iowa Department of Public Health, September 2011
    Care plan agreement form between a client and case manager on the goals and objectives of care (Who, What, Where, How, When, How Often, Progress/Outcome/Date).
  • HRSA HIV/AIDS Bureau, June 2004

    Collection of tools (e.g., client interview form, outreach encounter, chart review, evaluation questions) for collecting information on contacts with clients enrolled in a SPNS supported multi site evaluation on outreach.

  • Matthew 25, January 2009

    Brief list of client responsibilities used by a Ryan White clinic in explaining what is expected of them, such as active engagement in the care plan, sharing of information with staff, and appropriate conduct.

  • Kentucky Department for Public Health, January 2007, HIV/AIDS Branch, January 2007

    Satisfaction survey for clients of Kentucky's HIV/AIDS Care Coordinator Program that seeks to facilitate the provision of care to HIV-infected individuals and their families.

  • Hartford Department of Health and Human Services
    Hartford Department of Health and Human Services, February 2010

    Form for staff to assess care plan needs of clients, every 6 months, in terms of case management, home health, respite, housing, mental health, substance abuse treatment, legal, and financial assistance.

  • Matthew 25, January 2009

    One page agreement for clients outlining their rights and responsibilities as clients of a clinic. Document discusses confidentiality, honest and open communication, managing health responsibly, and keeping the clinic informed about financial and lifestyle changes.

  • Seattle-King County Public Health, January 2010

    Quarterly consumer awareness campaigns to improve the quality of care for people with HIV in Seattle-King County. The campaigns include posters, information cards, and buttons that HIV providers wear to reinforce the message and encourage conversations with clients.

  • Truman Medical Center, January 2009
    Series of one-page surveys to assess client understanding of each of the following: medications, health maintenance, HIV and transmission, lab tests/health problems, information.
  • El Rio Health Center, January 2009, Inc., January 2009

    Client-administered assessment tools to assist clinicians in working with clients on adherence to medication regimens. 

  • Missouri Department of Health and Senior Services, December 2009

    Missouri HIV case management manual outlines policies, standards, roles and responsibilities, monitoring, recordkeeping, and more.

  • Christiana Care Health Services, January 2009

    Clinician assessment tool to use with clients in assessing their readiness to engage in HIV-related primary medical care and adhere to regimens.

  • Variables used in New York City jails to assess needs of PLWHA pre-release and during transition to the community.


  • University of Connecticut, January 2007, Center for Health, January 2007, Intervention, January 2007, and Prevention, January 2007

    Tools to help clinics implement HIV prevention (risk reduction) with their HIV-positive patients, using such techniques as brief motivational interviewing and a plan of action for patients. OPTIONS was field-tested by Ryan White SPNS projects.

  • Linking to Care
    Philadelphia Office of HIV Planning, May 2014

    This is a brief assessment tool for counselors and testing staff to use with persons newly-diagnosed with HIV to assess their linkages to care in terms of health coverage, finances, housing, and social supports.

Training resources

  • Boston University School of Public Health Health and Disability Working Group, June 2003

    Cross-disciplinary training curriculum to increase knowledge and awareness of the relationship between HIV infection and substance use.

  • Stop the Drop
    Pacific AETC, February 2014

    Online trainings to help providers address care challenges that stand in the way of clients accessingn testing, linkage, care and engagement in HIV services. 


Best practices