Special Projects Fund

Grantee Name

Housing Works, Inc.

Funding Area

Special Projects Fund

Publication Date

January 2017

Grant Amount


Grant Date:

November 2015 – September 2016

Despite advances in medicine, the AIDS epidemic continues to be a major public health concern—especially in New York City, which remains an epicenter of the disease.

During 2013, New York City recorded 2,832 new HIV diagnoses and 1,784 new AIDS diagnoses. Currently, more than 117,000 people are living with diagnosed HIV infection in New York City, many of whom come from vulnerable populations. Federal guidelines recommend antiretroviral (ARV) medication for all people living with HIV. ARV treatment suppresses the level of HIV in the blood to an undetectable level, which enables HIV-positive people to live healthy lives while making it virtually impossible to transmit the virus to others. Although ARV is highly effective and is now the established standard of care, only 43% of HIV-positive New York City residents have achieved viral suppression.

In 2015, NYHealth awarded Housing Works a grant to scale up a successful viral load suppression model, The Undetectables, to help those living with HIV manage the disease and prevent its further transmission. This evidence-based model has been shown to successfully suppress the virus in 82% of participants. Under this grant, Housing Works aimed to expand The Undetectables model and form a consortium to collectively adopt, refine, and scale up the model throughout New York City.

Outcomes and Lessons Learned

  • Led a consortium of partners (including New York City Department of Health and Mental Hygiene (DOHMH), Amida Care, members of the Community Care of Brooklyn Performing Provider System, and Mt. Sinai Performing Provider System) to explore the model, identify essential elements, and help DOHMH settle on programmatic criteria for successful scale-up throughout the City and beyond;
  • Developed a plan for training and technical assistance on site-specific implementation, best-practice case management, quality improvement-focused management, social media marketing, and the program’s fiscal sustainability; and
  • Began preparing for the shift to value-based payment through New York State’s Delivery System Reform Incentive Payment (DSRIP) program by convening the DSRIP HIV Coalition, a group of stakeholders from seven New York City Performing Provider Systems (PPSs) working on HIV-related projects.

With NYHealth support, Housing Works laid the groundwork for DOHMH to fund agencies to implement the model in new geographic settings and for different populations of persons with HIV who face significant barriers to medication adherence. As a result, DOHMH awarded more than $1.5 million in contracts to seven agencies to implement The Undetectables program beginning in 2017. Housing Works also continues to serve as convener of the DSRIP HIV Coalition to help advance implementation of The Undetectables model among the participating PPSs.

In January 2017, Housing Works and DOHMH launched a citywide media campaign to raise awareness about The Undetectables model and its connection to Governor Cuomo’s statewide HIV/AIDS reduction blueprint, Ending the Epidemic 2020.

As part of its ongoing DSRIP efforts, Housing Works is working with partners, such as Amida Care, to advocate for financial incentives for viral suppression to be covered by Medicaid managed care organizations. Over the course of the grant, Housing Works met with staff from the New York State Department of Health and the Cuomo administration to advocate for funding of viral load suppression projects via DSRIP. Although this effort is ongoing, Governor Cuomo announced in December 2016 that all organizations and providers (clinical and nonclinical) serving HIV patients will now be required to track their patients’ viral load on a quarterly basis.

Housing Works accomplished many of its target goals and is still on track to accomplish others, but parts of the project took longer than expected. This experience will inform how much time to allocate for similar projects in the future.

Co-Funding and Additional Funds Leveraged: DOHMH awarded more than $1.5 million in contracts to seven agencies to implement The Undetectables program. DOHMH also awarded Housing Works an additional grant to provide technical assistance to these agencies ($242,992).