HRSA-22-031 (U90) SURE-ITAP_final.pdf

U.S. Department of Health and Human Services

HIV/AIDS Bureau

Division of Policy and Data

Supporting Replication (SURE) of Housing Interventions in the Ryan White HIV/AIDS Program – Implementation and Technical Assistance Provider

Funding Opportunity Number: HRSA-22-031

Funding Opportunity Type: New

Assistance Listings (AL/CFDA) Number: 93.928

NOTICE OF FUNDING OPPORTUNITY

Fiscal Year 2022

Letter of Intent Requested by: January 21, 2022

Application Due Date: February 23, 2022 Ensure your SAM.gov and Grants.gov registrations and passwords are current immediately!

HRSA will not approve deadline extensions for lack of registration.

Registration in all systems may take up to 1 month to complete.

Issuance Date: November 22, 2021

Adan Cajina, MSOR Chief, Special Projects of National Significance Branch Telephone: (301) 443-3180 Email: ACajina@hrsa.gov

See Section VII for a complete list of agency contacts.

Authority: 42 USC § 300ff-101 (§ 2691 of the Public Health Service Act) mailto:ACajina@hrsa.gov

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508 Compliance Disclaimer Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, please email or call one of the HRSA staff in Section VII.

Agency Contacts.

EXECUTIVE SUMMARY

The Health Resources and Services Administration (HRSA) is accepting applications for the fiscal year (FY) 2022 Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program Initiative titled Supporting Replication (SURE) of Housing Interventions in the Ryan White HIV/AIDS Program (SURE Housing).

The SURE Housing initiative has two separate yet coordinated recipients: the Implementation and Technical Assistance Provider (ITAP) funded under this announcement (HRSA-22-031); and an Evaluation Provider (EP) funded under a different announcement (HRSA-22-032). Both the ITAP and the EP must coordinate activities and share information and data in the design, implementation, evaluation, communication, and dissemination of this initiative. The success of this initiative is dependent on the collective success of the individual components, with the ultimate goal of communicating and disseminating replication tools to the broader RWHAP, HIV, and housing communities.

The purpose of this funding announcement (HRSA-22-031) is to support a single organization that will serve as the ITAP to provide technical assistance to up to 10 sites (“implementation sites”) implementing and adapting housing-related evidence-based interventions, evidence-informed interventions, and emerging strategies (collectively, “intervention strategies”) for the following three key populations of people with HIV experiencing unstable housing: 1) lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) people; 2) youth and young adults (ages 13-24); and 3) people who have been justice involved (i.e., people impacted by the justice system).

The ITAP will select and fund implementation sites under individual subawards; provide implementation-related technical assistance to the sites; and develop a communication plan and replication tools for widespread adoption of these housing-related intervention strategies for these three key populations of people with HIV experiencing unstable housing. The EP, funded under the companion announcement (HRSA-22-032), will develop and implement a multi-site evaluation of these intervention strategies and provide evaluation-related technical assistance using an implementation science framework. The ITAP will support the EP and implementation sites in carrying out the multi-site evaluation.

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This program notice is subject to the appropriation of funds, and is a contingency action taken to ensure that, should funds become available for this purpose, HRSA can process applications and award funds appropriately. This program may be cancelled prior to award.

Funding Opportunity Title:

Supporting Replication (SURE) of Housing Interventions in the Ryan White HIV/AIDS Program – Implementation and Technical Assistance Provider

Funding Opportunity Number: HRSA-22-031

Due Date for Applications: February 23, 2022

Anticipated Total Annual Available FY 2022 Funding:

$3,500,000

Estimated Number and Type of Award: One (1) cooperative agreement

Estimated Annual Award Amount:

Up to $3,500,000 per year subject to the availability of appropriated funds

Cost Sharing/Match Required: No

Period of Performance: August 1, 2022 through July 31, 2026

(4 years)

Eligible Applicants: Eligible applicants include entities eligible for funding under Ryan White HIV/AIDS Program Parts A - D of Title XXVI of the Public Health Service (PHS) Act, including public and nonprofit private entities; state and local governments;

academic institutions; local health departments; nonprofit hospitals and outpatient clinics; community health centers receiving support under Section 330 of the PHS Act; faith-based and community-based organizations; and Indian Tribes or Tribal organizations with or without federal recognition.

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See Section III.1 of this notice of funding opportunity (NOFO) for complete eligibility information.

Application Guide

You (the applicant organization/agency) are responsible for reading and complying with the instructions included in HRSA’s SF-424 Application Guide, available online, except where instructed in this NOFO to do otherwise.

Technical Assistance

HRSA has scheduled the following technical assistance:

Webinar

Day and Date: Monday, December 13, 2021 Time: 2 p.m. – 3:30 p.m. ET

Weblink: Join ZoomGov Meeting https://hrsa-gov.zoomgov.com/j/1613730153?pwd=TEordlQ2aitMNVRRbXZyR0hxZDZBdz09 Meeting ID: 161 373 0153 Passcode: qvi6Q2px

Or Dial-In Call-In Number: 1-833-568-8864 (US Toll-free) Meeting ID: 161 373 0153 Passcode: 34174265

Playback: The webinar will be recorded and should be available within 10 business days on the TargetHIV website. Answers to questions posed before and during the webinar will also be posted there.

http://www.hrsa.gov/grants/apply/applicationguide/sf424guide.pdf https://hrsa-gov.zoomgov.com/j/1613730153?pwd=TEordlQ2aitMNVRRbXZyR0hxZDZBdz09 https://hrsa-gov.zoomgov.com/j/1613730153?pwd=TEordlQ2aitMNVRRbXZyR0hxZDZBdz09 https://targethiv.org/library/nofos

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Table of Contents

EXECUTIVE SUMMARY ........................................................................................................ I APPLICATION GUIDE ............................................................................................................... III TABLE OF CONTENTS ............................................................................................................. IV

I. PROGRAM FUNDING OPPORTUNITY DESCRIPTION

1. Purpose

2. Background

II. AWARD INFORMATION

1. Type of Application and Award

2. Summary of Funding

III. ELIGIBILITY INFORMATION

1. Eligible Applicants

2. Cost Sharing/Matching

3. Other

IV. APPLICATION AND SUBMISSION INFORMATION

1. Address to Request Application Package

2. Content and Form of Application Submission

PROGRAM REQUIREMENTS AND EXPECTATIONS

PROGRAM-SPECIFIC INSTRUCTIONS

i. Project Abstract

NARRATIVE GUIDANCE

ii. Project Narrative

iii. Budget

iv. Budget Narrative

v. Attachments

3. Dun and Bradstreet Data Universal Numbering System (DUNS) Number Transition to the Unique Entity Identifier (UEI) and System for Award Management

(SAM)

4. Submission Dates and Times

5. Intergovernmental Review

6. Funding Restrictions

7. Other Submission Requirements

V. APPLICATION REVIEW INFORMATION

1. Review Criteria

2. Review and Selection Process

3. Assessment of Risk

VI. AWARD ADMINISTRATION INFORMATION

1. Award Notices

2. Administrative and National Policy Requirements

3. Reporting

VII. AGENCY CONTACTS

VIII. OTHER INFORMATION

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I. Program Funding Opportunity Description

1. Purpose

This notice announces the opportunity to apply for funding under the Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program1 project titled Supporting Replication (SURE) of Housing Interventions in the Ryan White HIV/AIDS Program - Implementation and Technical Assistance Provider

(ITAP).

The purpose of this project is to support a single organization that will serve as an ITAP to provide technical assistance (TA) to up to 10 implementation sites that will implement and adapt housing-related intervention strategies for the following three key populations of people with HIV experiencing unstable housing, who often have the highest HIV-related disparities (see Background Section I.2):

1) lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) people;

2) youth and young adults (ages 13-24); and

3) people who have been justice involved (i.e., people impacted by the justice system).

The SURE Housing initiative has two separate, yet coordinated recipients: the ITAP, which will be funded under this announcement (HRSA-22-031), and an Evaluation Provider (EP), funded under a different announcement (HRSA-22-032), which will use an implementation science framework2 to evaluate the implementation and adaptation of the housing intervention strategies. Both the ITAP and the EP must coordinate activities and share information and data in the design, implementation, evaluation, communication, and dissemination of this initiative. The success of this initiative is dependent on the collective success of the individual components, with the ultimate goal of communicating and disseminating replication tools to the broader RWHAP, HIV, and housing communities.

The ITAP will identify potential intervention strategies that can be adapted for the key populations identified, using criteria that assess feasibility, adaptability, and effectiveness. The ITAP will also develop and quickly release an application process to select and fund the implementation sites under individual subawards (up to $250,000/site per year); provide TA to the sites in implementing and adapting these interventions; and develop replication tools for widespread adoption of these intervention strategies for the above three key populations of people with HIV experiencing unstable housing.

1 HRSA Ryan White HIV/AIDS Program Part F: Special Projects of National Significance (SPNS) Program.

Available at: https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-f-special-projects-national-significance-spns-program 2 Psihopaidas D, Cohen SM, West T, et al.; Implementation science and the Health Resources and Services Administration’s Ryan White HIV AIDS Program’s work towards ending the HIV epidemic in the United States.

PLoS Med 2020;17(11):e1003128. Available at: https://doi.org/10.1371/journal.pmed.1003128 https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-f-special-projects-national-significance-spns-program https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-f-special-projects-national-significance-spns-program https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-f-special-projects-national-significance-spns-program https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-f-special-projects-national-significance-spns-program https://doi.org/10.1371/journal.pmed.1003128

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This initiative will engage and retain people with HIV experiencing unstable housing in HIV medical care and support services by addressing their housing and behavioral health needs, as needed. Thus, the proposed housing intervention strategies should include models to integrate behavioral health services, including mental health and substance use disorder treatment, with HIV care to specifically address the comprehensive needs of people with HIV experiencing unstable housing to improve health outcomes.

In addition, the implementation sites will participate in a multi-site evaluation to assess the effectiveness of the interventions’ implementation and adaption. The ITAP will work collaboratively with the EP and HRSA staff in all aspects of the planning, implementation, adaptation, provision of TA, and evaluation of the housing-related intervention strategies. The ITAP will also develop adaptation manuals prior to the implementation of these interventions. Finally, the ITAP will actively disseminate the initiative’s findings, lessons learned, and outcomes for future replication in other settings.

Recognizing the critical role of housing in supporting people with HIV to improve health outcomes, HRSA will draw upon the expertise of the U.S. Department of Housing and Urban Development (HUD), including its Office of HIV/AIDS Housing (OHH), which administers the Housing Opportunities for Persons With AIDS (HOPWA) Program.3 HUD is responsible for national policy and programs that address America's housing needs and enforce fair housing laws. As such, HRSA will consult with HUD as needed for the purposes of this initiative.

The ultimate goal of this initiative is to promote the replication of effective housing interventions in the RWHAP to decrease health and housing disparities and improve health outcomes along the HIV care continuum. Thus, the ITAP and implementation sites should partner with relevant housing organizations, housing consortiums, HUD’s Continuum of Care (CoC) Program,4 and planning councils, to address unmet housing needs. In addition, for a wider reach in order to leverage services and have broad impact, applicants should consider partnerships with LGBTQ+ organizations, youth organizations, and correctional/justice-involved institutions.

HUD Exchange. Housing Opportunities for Persons With AIDS (HOPWA) Program. , Available at: https://www.hudexchange.info/programs/hopwa/

For more details, see Program Requirements and Expectations.

2. Background

The RWHAP SPNS Program is authorized by 42 USC § 300ff-101 (§ 2691 of the Public Health Service Act).

3 HUD Exchange. Housing Opportunities for Persons With AIDS (HOPWA) Program. , Available at:

https://www.hudexchange.info/programs/hopwa/ 4 HUD Exchange. HUD’s Continuum of Care Program. Available at: https://www.hudexchange.info/programs/coc/ https://www.hudexchange.info/programs/hopwa/ https://www.hudexchange.info/programs/coc/ https://www.hudexchange.info/programs/hopwa/ https://www.hudexchange.info/programs/hopwa/ https://www.hudexchange.info/programs/coc/

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The RWHAP provides a comprehensive system of HIV primary medical care, essential support services, and medications for low-income people with HIV. The program funds grants to states, cities, counties, and local community-based organizations to provide care and treatment services to people with HIV to improve health outcomes and reduce HIV transmission among hard-to-reach populations.

The RWHAP has five statutorily defined Parts (Parts A, B, C, D, and F) that provide funding for core medical care, support services, and medications; TA; clinical training;

and the development of innovative models of care to meet the needs of different communities and populations affected by HIV.

An important framework in the RWHAP is the HIV care continuum, which depicts the series of stages a person with HIV engages in from initial diagnosis through their successful treatment with HIV medication to achieve viral suppression. Supporting people with HIV to reach viral suppression not only increases their own quality of life and lifespan, it also prevents sexual transmission to an HIV-negative partner.

The HIV care continuum framework allows recipients and planning groups to measure progress and to direct HIV resources most effectively. RWHAP recipients are encouraged to assess the outcomes of their programs and should work with their community and public health partners to improve outcomes across the HIV care continuum. HRSA encourages recipients to use the performance measures developed for the RWHAP at their local level to assess the efficacy of their programs and to analyze and improve the gaps along the HIV care continuum.

Strategic Frameworks and National Objectives

National objectives and strategic frameworks like the Healthy People 2030, the HIV National Strategic Plan: A Roadmap to End the HIV Epidemic in the U.S. (2021–2025);

the Sexually Transmitted Infections National Strategic Plan for the United States (2021–2025); and the Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination (2021–2025) are crucial to addressing key public health challenges facing low-income people with HIV. These strategies detail the principles, priorities, and actions to guide the national public health response and provides a blueprint for collective action across the Federal Government and other sectors. The RWHAP supports the implementation of these strategies and recipients should align their organization’s efforts, within the parameters of the RWHAP statute and program guidance, with these strategies to the extent possible.

Expanding the Effort: Ending the HIV Epidemic in the United States

According to recent data from the 2019 Ryan White Services Report (RSR), the RWHAP has made tremendous progress toward ending the HIV epidemic in the United States. From 2015 to 2019, HIV viral suppression among RWHAP patients who have had one or more medical visits during the calendar year and at least one viral load with a result of <200 copies/mL reported, has increased from 83.4 percent to 88.1 percent.

Additionally, racial/ethnic, age-based, and regional disparities reflected in viral http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html https://health.gov/healthypeople https://www.hiv.gov/federal-response/hiv-national-strategic-plan/hiv-plan-2021-2025 https://www.hiv.gov/federal-response/hiv-national-strategic-plan/hiv-plan-2021-2025 https://www.hhs.gov/programs/topic-sites/sexually-transmitted-infections/plan-overview/index.html https://www.hhs.gov/programs/topic-sites/sexually-transmitted-infections/plan-overview/index.html https://www.hhs.gov/hepatitis/viral-hepatitis-national-strategic-plan/national-viral-hepatitis-action-plan-overview/index.html https://www.hhs.gov/hepatitis/viral-hepatitis-national-strategic-plan/national-viral-hepatitis-action-plan-overview/index.html https://hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-client-level-data-report-2019.pdf

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suppression rates have significantly decreased.5 For example, the disparities in viral suppression rates between Black/African Americans and White clients have decreased since 2010.6 These improved outcomes mean more people with HIV in the United States will live near normal lifespans and have a reduced risk of transmitting HIV to others.7

In February 2019, the Ending the HIV Epidemic in the United States (EHE) initiative was launched to further expand federal efforts to reduce HIV infections. This 10-year initiative seeks to achieve the important goal of reducing new HIV infections in the United States to fewer than 3,000 per year by 2030. The initiative promotes and implements four strategies to substantially reduce HIV transmissions – Diagnose, Treat, Prevent, and Respond. The initiative is a collaborative effort among key U.S.

Department of Health and Human Services (HHS) agencies, primarily HRSA, the CDC, the National Institutes of Health (NIH), the Indian Health Service (IHS), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

For the RWHAP, the EHE initiative expands the program’s ability to meet the needs of clients, specifically focusing on linking people with HIV who are either newly diagnosed, diagnosed but currently not in care, or are diagnosed and in care but not yet virally suppressed, to the essential HIV care, treatment, and support services needed to help them achieve viral suppression.

Using Data Effectively: Integrated Data Sharing and Use

HRSA and CDC’s Division of HIV/AIDS Prevention support integrated data sharing, analysis, and utilization for the purposes of program planning, conducting needs assessments, determining unmet need estimates, reporting, quality improvement, enhancing the HIV care continuum, and public health action. HRSA strongly encourages RWHAP recipients to:

• Follow the principles and standards in the Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Programs: Standards to Facilitate Sharing and Use of Surveillance Data for Public Health Action.

• Establish data sharing agreements between surveillance and HIV programs to ensure clarity about the process and purpose of the data sharing and utilization.

Integrated data sharing, analysis, and utilization of HIV data by state and territorial health departments can help further progress toward reaching the HIV National Strategic Plan goals and improve outcomes on the HIV care continuum.

5 Health Resources and Services Administration. Ryan White HIV/AIDS Program Annual Client-Level Data Report 2019. Published December 2020. Accessed December 2, 2020. Available at: http://hab.hrsa.gov/data/data-reports.

6 Black/African American clients went from 79.4 percent viral suppression in 2015 to 85.2 percent in 2019, while

88.3 percent of White clients were virally suppressed in 2015 and 91.8 percent in 2019 7 National Institute of Allergy and Infectious Diseases (NIAID). Preventing Sexual Transmission of HIV with Anti- HIV Drugs. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2016 Mar 29]. Available at: https://clinicaltrials.gov/ NCT00074581 NLM Identifier: NCT00074581.

https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview/ending-epidemic-timeline http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://www.cdc.gov/nchhstp/programintegration/docs/pcsidatasecurityguidelines.pdf http://hab.hrsa.gov/data/data-reports https://clinicaltrials.gov/

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HRSA strongly encourages complete CD4, viral load (VL), and HIV nucleotide sequence reporting to the state and territorial health departments’ HIV surveillance systems to benefit fully from integrated data sharing, analysis, and utilization. State health departments may use CD4, VL, and HIV nucleotide sequence data to identify cases, stage of HIV disease at diagnosis, and monitor disease progression. These data can also be used to evaluate HIV testing and prevention efforts, determine entry into and retention in HIV care, measure viral suppression, monitor prevalence of antiretroviral drug resistance, detect transmission clusters and understand transmission patterns, and assess unmet health care needs. Analyses at the national level to monitor progress toward ending the HIV epidemic in the United States can only occur if all HIV-related CD4, VL, and HIV nucleotide sequence test results are reported by all jurisdictions. CDC requires the reporting to the National HIV Surveillance System (NHSS) all HIV-related CD4 results (counts and percentages), all VL results (undetectable and specific values), and HIV nucleotide sequences.

Program Resources and Innovative Models

HRSA has a number of projects and resources that may assist RWHAP recipients with program implementation. These include a variety of HRSA HIV/AIDS Bureau (HAB) cooperative agreements, contracts, and grants focused on specific TA, evaluation, and intervention activities. A list of these resources is available on TargetHIV. Recipients should be familiar with these resources and are encouraged to use them as needed to support their program implementation.

In addition, many RWHAP Special Projects of National Significance (SPNS) projects have demonstrated promising new approaches for linking and retaining priority populations into care. As resources permit, RWHAP recipients are encouraged to review and integrate these tools within their HIV system of care in accordance with the allowable service categories defined in Policy Clarification Notice (PCN) 16-02 Ryan White HIV/AIDS Program Services: Eligible Individuals & Allowable Uses of Funds.

Examples of these resources include:

• E2i: Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV E2i uses an implementation science approach to evaluate and understand existing and new intervention strategies that can be used in RWHAP provider settings. Once interventions or strategies are demonstrated and evaluated using implementation science, manuals, guides, interactive online tools, publications, and instructional materials are developed and disseminated for replication and integration into RWHAP provider settings.

• Integrating HIV Innovative Practices (IHIP) Resources on the IHIP website include easy-to-use training manuals, curricula, case studies, pocket guides, monographs, and handbooks, as well as informational handouts and infographics about SPNS generally. IHIP also hosts TA training webinars designed to provide a more interactive experience with experts, and a TA https://targethiv.org/help/ta-directory https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://targethiv.org/e2i https://targethiv.org/e2i https://targethiv.org/ihip

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help desk exists for you to submit additional questions and share your own lessons learned.

• Replication Resources from the SPNS Systems Linkages and Access to Care There are intervention manuals for patient navigation, care coordination, state bridge counselors, data to care, and other interventions developed for use at the state and regional levels to address specific HIV care continuum outcomes among hard-to-reach people with HIV.

• Dissemination of Evidence Informed Interventions The Dissemination of Evidence-Informed Interventions initiative ran from 2015-2020 and disseminated four adapted linkage and retention interventions from prior SPNS and the Minority HIV/AIDS Funds (MHAF) from the HHS Secretary’s Office initiatives to improve health outcomes along the HIV care continuum. The initiative produced four evidence-informed care and treatment interventions (CATIs) that are replicable, cost-effective, capable of producing optimal HIV care continuum outcomes, and easily adaptable to the changing health care environment. Manuals are currently available at the link provided and will be updated on an ongoing basis.

HRSA HAB also recognizes the importance of addressing emerging issues, as well as supporting the needs of special populations. To help recipients in responding to these critical issues, HRSA HAB funds projects to provide technical assistance and resources for recipients. Examples of projects include:

• Building Futures: Supporting Youth Living with HIV

• The Center for Engaging Black MSM Across the Care Continuum (CEBACC)

• Using Community Health Workers to Improve Linkage and Retention in Care

The SPNS Program supports the development of innovative models of HIV care to quickly respond to the emerging needs of clients served by the Ryan White HIV/AIDS Program. The SPNS Program evaluates the effectiveness of these models’ design, implementation, utilization, cost, and health-related outcomes while promoting the communication, dissemination, and replication of successful models.

HRSA is publishing this notice of funding opportunity (NOFO) in conjunction with Supporting Replication (SURE) of Housing Interventions in the Ryan White HIV/AIDS Program – Evaluation Provider (HRSA-22-032). Because award recipients under both NOFOs (HRSA-22-031 and HRSA-22-032) will need to work closely together to be successful, HAB encourages you to read the companion announcement and become familiar with all program expectations within each NOFO.

The HRSA HAB Implementation Science Approach

The goal of this initiative is to identify, implement, and adapt intervention strategies that could be effective for improving outcomes among the three key populations of people with HIV identified in this NOFO who are served by the RWHAP, thereby reducing disparities and moving toward ending the HIV epidemic in the U.S within the HRSA HAB https://targethiv.org/library/replication-resources-spns-systems-linkages-and-access-care https://targethiv.org/deii https://targethiv.org/library/hrsa-hab-building-futures-supporting-youth-living-hiv https://targethiv.org/cebacc https://targethiv.org/chw

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implementation science framework (HAB IS).8 HAB IS was developed to support the translation of insights from the implementation science literature to real-world settings.

HAB IS includes effectiveness criteria for three categories of intervention strategies for the RWHAP: evidence-based interventions, evidence-informed interventions, and emerging strategies. HRSA HAB developed these criteria in collaboration with the CDC and the NIH. This initiative will focus on housing-related intervention strategies across these three categories. By focusing on these intervention strategies, HRSA seeks to replicate RWHAP SPNS and other housing-related intervention strategies for the above three key populations of people with HIV experiencing unstable housing.

HIV, Housing Disparities, and Key Populations

Promoting equity is essential to HHS’ mission of protecting the health of Americans and providing essential human services. This view is reflected in Executive Order 139859 entitled Advancing Racial Equity and Support for Underserved Communities through the Federal Government. Addressing issues of equity should include an understanding of intersectionality and how multiple forms of discrimination impact individuals’ lived experiences.10

Structural and social determinants of health such as housing,11 employment,12 and disparate service delivery systems13 are often associated with HIV-related health disparities. Housing stability has a particular impact on the health of people with HIV.

Homelessness was associated with 3.84 times the likelihood of incomplete viral suppression when compared to people with HIV who were stably housed.14 People with HIV experiencing homelessness are at increased risk of poorer mental, physical, and overall health status.15 Thus, housing is a potentially important mechanism for

8 Psihopaidas D, Cohen SM, West T, et al.; Implementation science and the Health Resources and Services Administration’s Ryan White HIV AIDS Program’s work towards ending the HIV epidemic in the United States.

PLoS Med 2020;17(11):e1003128. https://doi.org/10.1371/journal.pmed.1003128 9 Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, 86 FR 7009, at § 2(a) (Jan. 20, 2021). Available at: https://www.govinfo.gov/content/pkg/FR- 2021-01-25/pdf/2021-01753.pdf.

10 See Executive Order 13988 on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation, 86 FR 2023, at § 1 (Jan. 20, 2021).Available at: https://www.govinfo.gov/content/pkg/FR-2021- 01-25/pdf/2021-01761.pdf.

11 Housing and Urban Development (HUD). The Connection Between Housing and Improved Outcomes Along the HIV Care Continuum, 2013. Available at: https://www.hudexchange.info/resources/documents/The-Connection- Between-Housing-and-Improved-Outcomes-Along-the-HIV-Care-Continuum.pdf 12 Conyers LM, Richardson LA, Datti PA, Koch LC, Misrok M. A Critical Review of Health, Social, and Prevention Outcomes Associated With Employment for People Living With HIV. AIDS Educ Prev. 2017;29(5):475-490.

doi:10.1521/aeap.2017.29.5.475. Available at: https://pubmed.ncbi.nlm.nih.gov/29068719/ 13 Mathematica Policy Research, 2014. Hargreaves M, Oddo V, Stillman L, Sherwood J, Sullivan S. Analysis of Integrated HIV Housing and Care Services. Available at: http://www.mathematica-mpr.com/~/media/publications/pdfs/health/hiv_housing_care_svcs.pdf 14 Thakarar K, Morgan JR, Gaeta JM, Hohl C, Drainoni ML. Homelessness, HIV, and Incomplete Viral Suppression. J Health Care Poor Underserved. 2016;27(1):145-156. doi:10.1353/hpu.2016.0020 Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982659/ 15 Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health.

https://doi.org/10.1371/journal.pmed.1003128 https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01761.pdf https://www.hudexchange.info/resources/documents/The-Connection-Between-Housing-and-Improved-Outcomes-Along-the-HIV-Care-Continuum.pdf https://www.hudexchange.info/resources/documents/The-Connection-Between-Housing-and-Improved-Outcomes-Along-the-HIV-Care-Continuum.pdf https://pubmed.ncbi.nlm.nih.gov/29068719/ http://www.mathematica-mpr.com/%7E/media/publications/pdfs/health/hiv_housing_care_svcs.pdf http://www.mathematica-mpr.com/%7E/media/publications/pdfs/health/hiv_housing_care_svcs.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982659/

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improving the health of people with HIV who have not yet been successfully maintained in care.

HRSA has identified three key focus populations for this project: LGBTQ+; youth and young adults; and justice involved individuals. HIV disproportionately affects the LGBTQ+ communities – in 2018, gay, bisexual, and other men who have sex with men (MSM) accounted for 69 percent of the 37,968 new HIV diagnoses in the United States.16 Similarly, youth and young adults ages 13-24 accounted for approximately 21 percent of new HIV diagnoses in 2018.17 In addition, those with recent incarceration history were more likely to experience homelessness and least likely to report HIV medication adherence and durable viral suppression compared to those who were never incarcerated.18

Specifically, data from the Ryan White HIV/AIDS Program Services Report (RSR) show that although viral suppression rates have increased over time in the RWHAP, challenges remain for certain populations, especially clients with temporary or unstable housing. Data from the 2019 RSR show that RWHAP clients with unstable housing have lower viral suppression rates (74.5 percent) than clients with stable housing (89.3 percent). In addition, key populations with unstable housing continue to have the lowest percentages of viral suppression: transgender people (67.5 percent); youth aged 13-24 years (69.3 percent); and Black/African American MSM (71.7 percent).19 These data underscore the importance of replicating effective structural and evidence-informed housing intervention strategies for these subpopulations across the RWHAP.

Implementation and Adaptation of Housing Intervention Strategies

The RWHAP SPNS program has extensive experience in funding demonstration project initiatives that implement and evaluate innovative models focused on improving access to and retention in care for people with HIV, including successful implementation and evaluation of three housing-related initiatives to improve health outcomes for people with HIV experiencing unstable housing (See Table 1).

Table 1. RWHAP SPNS Housing-Related Initiatives

2007;97(12):2238-2245. doi:10.2105/AJPH.2006.090209. Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2089119/ 16 Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated);

vol.31. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2020.

17 Centers for Disease Control and Prevention. HIV and Youth: HIV Incidence, 2018. Available at:

https://www.cdc.gov/hiv/group/age/youth/incidence.html 18 Ibañez, G.E., Zhou, Z., Algarin, A.B. et al. Incarceration History and HIV Care Among Individuals Living with HIV in Florida, 2014–2018. AIDS Behav 25, 3137–3144 (2021). https://doi.org/10.1007/s10461-021-03250-8 19 Health Resources and Services Administration. 2019 Ryan White HIV/AIDS Program Annual Client-Level Data Report. Available at: https://hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-client-level-data-report-2019.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2089119/ http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html https://www.cdc.gov/hiv/group/age/youth/incidence.html https://hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-client-level-data-report-2019.pdf https://hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-client-level-data-report-2019.pdf

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Evidence- Informed Interventions and Emerging Strategies

Summary Website

Building a Medical Home for Multiply Diagnosed HIV Positive Homeless Populations

The goals of these interventions were to improve the timely entry, engagement, and retention in HIV care and support services for homeless and unstably housed people with HIV with co-occurring mental illness and/or substance use disorders. The interventions employed models of care focused on the development of sustainable linkages to mental health, substance abuse treatment, and HIV primary care services for homeless or unstably housed people with HIV.

Demonstration sites provided intensive coordination of care and service needs, including integrated and co-located HIV primary care, substance abuse, and mental health treatment services within an HIV primary care clinic, public housing facility, or network of providers.

https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-homeless-populations https://www.targethiv.org/library /building-medical-homes-multiply-diagnosed-hiv-positive-homeless-populations

Addressing HIV Care and Housing Coordination through Data Integration

These interventions supported the electronic integration of housing and HIV care data and implementation of enhanced coordinated service delivery strategies between HRSA's RWHAP and HUD’s HOPWA program.

https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-data-integration https://www.targethiv.org/library /spns-housing-data-integration

Improving HIV Health Outcomes through the Coordination of Supportive

The overall goal of these coordinated services interventions was to decrease the negative impact of the social determinants of health that affect long-term HIV health outcomes for people https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-homeless-populations https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-homeless-populations https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-homeless-populations https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-homeless-populations https://www.targethiv.org/library/building-medical-homes-multiply-diagnosed-hiv-positive-homeless-populations https://www.targethiv.org/library/building-medical-homes-multiply-diagnosed-hiv-positive-homeless-populations https://www.targethiv.org/library/building-medical-homes-multiply-diagnosed-hiv-positive-homeless-populations https://www.targethiv.org/library/building-medical-homes-multiply-diagnosed-hiv-positive-homeless-populations https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-data-integration https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-data-integration https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-data-integration https://www.targethiv.org/library/spns-housing-data-integration https://www.targethiv.org/library/spns-housing-data-integration https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html https://hab.hrsa.gov/about-ryan-white-hivaids-program/spns-initiative-improving-hiv-health-outcomes.html

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Employment and Housing Services with HIV impacted by employment and housing instability in racial and ethnic minority communities. This strategy integrated HIV care, housing, and employment services into a coordinated intervention.

https://targethiv.org/housing-and-employment

Throughout the course of these past initiatives, HRSA regularly consulted with HUD OHH for guidance and TA on housing-related issues. HRSA will continue to leverage the knowledge and expertise of HUD staff throughout the course of this initiative.

HRSA also acknowledges other interventions funded outside of RWHAP SPNS as a potential source of housing-related intervention strategies. These may include, but are not limited to, intervention strategies from HUD HOPWA and other innovative HIV and housing-related models.

One such intervention involves rapidly delivering housing services to people with HIV. In a 2019 New York City study, 236 people with HIV assigned to rapid re-housing (i.e., immediate assignment to a case manager to rapidly re-house a client and provide case management services) found housing faster and were more than twice as likely to achieve or maintain viral suppression as compared to those who were assigned to standard housing services and assistance.20

In another intervention, researchers established a POP-UP low-threshold, no appointment primary care program for people with HIV experiencing unstable housing.

One aspect of this care involved delivering prescribed medicine to the clinic itself so that the patients had direct access to their medication. By six months, 55 percent of the participants of the program achieved viral suppression.21

However, more needs to be done to extend the uptake and reach of these and other housing-related intervention strategies, especially in focus populations, who continue to experience health and housing disparities, to assure rapid replication and better integrate these interventions across RWHAP provider organizations. Successful dissemination and wider-scale replication of these intervention strategies will be key in improving health outcomes for people with HIV experiencing unstable housing to support ending the HIV epidemic across the U.S.

Key Definitions

20 Towe VL, Wiewel EW, Zhong Y, Linnemayr S, Johnson R, Rojas J. A Randomized Controlled Trial of a Rapid Re-housing Intervention for Homeless Persons Living with HIV/AIDS: Impact on Housing and HIV Medical Outcomes. AIDS Behav. 2019 Sep;23(9):2315-2325. doi: 10.1007/s10461-019-02461-4. PMID: 30879212.

Available at: https://pubmed.ncbi.nlm.nih.gov/30879212/ 21 Imbert E, Hickey MD, Clemenzi-Allen A, Lynch E, Friend J, Kelley J, Conte M, Das D, Rosario JBD, Collins E, Oskarsson J, Hicks ML, Riley ED, Havlir DV, Gandhi M. Evaluation of the POP-UP programme: a multicomponent model of care for people living with HIV with homelessness or unstable housing. AIDS. 2021 Jul 1;35(8):1241- 1246. doi: 10.1097/QAD.0000000000002843. PMID: 34076613; PMCID: PMC8186736. Available at:

https://pubmed.ncbi.nlm.nih.gov/34076613/ https://targethiv.org/housing-and-employment https://targethiv.org/housing-and-employment https://pubmed.ncbi.nlm.nih.gov/30879212/ https://pubmed.ncbi.nlm.nih.gov/34076613/

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For the purposes of this initiative, applicants should use the following definitions:

• Evidence-based interventions are strategies, models, or approaches that have been proven effective at improving the care and treatment of people with HIV.

Evidence-based interventions have demonstrated impact and strength of published research evidence and have met the evidence-based criteria established by the Centers for Disease Control and Prevention (CDC).

• Evidence-informed interventions22 are strategies, models, or approaches that have been proven effective or have shown promise as a methodology, practice, or means of improving the care and treatment of people with HIV. Evidence-informed should be understood as distinct from evidence-based., Evidence-informed interventions may demonstrate impact and strength of published research evidence without meeting CDC or other criteria for being evidence-based.

• Emerging strategies are innovative strategies that address emerging priorities for the care and treatment of people with HIV. Real world validity and effectiveness have been demonstrated, but emerging strategies do not yet have sufficient published research evidence.

• HIV care services are all of the HIV care and treatment services allowable through the RWHAP. For more information regarding RWHAP eligible services, refer to Policy Clarification Notice (PCN) #16-02: Ryan White HIV/AIDS Program Services: Eligible Individuals and Allowable Uses of Funds.23

• Housing services are the full range of rental, utility, security deposit, and mortgage assistance offered through HUD, including the HOPWA program, the Continuum of Care Program, and Emergency Solutions Grants Program, to stabilize individuals and families experiencing unstable housing or homelessness. In addition, please see the HRSA HAB program letter, Using Ryan White HIV/AIDS Program Funds to Support Housing Services.24

• Unstable housing includes but is not limited to literal homelessness (i.e., lacking a fixed, regular, and adequate nighttime residence, including sleeping in a place not meant for human habitation, such as a park bench, vehicle, bus, train or subway station, abandoned building, or anywhere outside, etc.);25 temporary housing (e.g., transitional housing, hotel or motel, or temporary arrangement with family or friends); and unstable housing arrangements (e.g., emergency shelter, 22 Psihopaidas D, Cohen SM, West T, et al.; Implementation science and the Health Resources and Services Administration’s Ryan White HIV AIDS Program’s work towards ending the HIV epidemic in the United States.

PLoS Med 2020;17(11):e1003128. Available at: https://doi.org/10.1371/journal.pmed.1003128

23 HRSA HIV/AIDS Bureau. Ryan White HIV/AIDS Program Services: Eligible Individuals & Allowable Uses of Funds Policy Clarification Notice (PCN)# 16-02. Available at: https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf 24 HRSA HIV/AIDS Bureau Program Letter Using Ryan White HIV/AIDS Program Funds to Support Housing Services. Available at: https://hab.hrsa.gov/sites/default/files/hab/Global/housingpolicyupdate0816_0.pdf 25 HUD Exchange. Definition of Homelessness. Available at:

https://files.hudexchange.info/resources/documents/HomelessDefinition_RecordkeepingRequirementsandCriteria.pd f https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://hab.hrsa.gov/sites/default/files/hab/Global/housingpolicyupdate0816_0.pdf https://hab.hrsa.gov/sites/default/files/hab/Global/housingpolicyupdate0816_0.pdf https://doi.org/10.1371/journal.pmed.1003128 https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf https://hab.hrsa.gov/sites/default/files/hab/Global/housingpolicyupdate0816_0.pdf https://files.hudexchange.info/resources/documents/HomelessDefinition_RecordkeepingRequirementsandCriteria.pdf https://files.hudexchange.info/resources/documents/HomelessDefinition_RecordkeepingRequirementsandCriteria.pdf

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jail, prison, or juvenile detention facility, or not having a lease, ownership interest, or occupancy agreement in permanent housing).26

• Justice involved refers to any person who is engaged at any point along the continuum of the criminal justice system as a defendant (including arrest, incarceration, and community supervision). See HRSA's Ryan White HIV/AIDS Program: Addressing the HIV Care Needs of People with HIV in State Prisons and Local Jails.27 For more information regarding RWHAP eligible services for people with HIV who are justice involved, refer to: Policy Clarification Notice (PCN) #18-02: The Use of Ryan White HIV/AIDS Program Funds for Core Medical Services and Support Services for People Living with HIV Who Are Incarcerated and Justice Involved.28

• Equity means the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.29

• Underserved Communities are populations sharing a particular characteristic, as well as geographic communities that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the preceding definition of “equity.”30

II. Award Information

1. Type of Application and Award

Type of applications sought: New

HRSA will provide funding in the form of a cooperative agreement. A cooperative agreement is a financial assistance mechanism where HRSA anticipates substantial involvement with the recipient during performance of the contemplated project.

26 HUD Exchange. HOPWA Annual Progress Report: Form HUD-40110-C. Definition of Unstable Housing Arrangements. Available at: https://www.hudexchange.info/resource/1012/hopwa-annual-progress-report-apr-form-hud-40110-c/ 27 HRSA RWHAP: Addressing the HIV Care Needs of People Living with HIV in State Prisons and Local Jails, Available at:…