This outcome evaluation effort provides the opportunity to learn what programmatic approaches effectively address two of the most difficult hurdles in HIV health services delivery: (1) getting people who would benefit from health care to use it and (2) getting people who do use health care to do so more consistently and effectively. The New York HIV Planning Council (through MHRA) has funded 23 agencies to achieve these objectives for people of color with HIV disease.

All clients are assessed upon entry into the program, have their service utilization tracked, and then are reassessed at three, six, and twelve months following program entry.

The main client-level data elements collected during baseline and follow-up interviews are the following:

• Biological markers (including HIV status, viral load, t-cell count)
• Demographic characteristics
• Adherence to treatment
• Barriers to care
• Social support
• Substance use and treatment
• Functional health status

Functional Health Status is used in this evaluation as the primary measure of final client "outcomes." The Functional Health Status items we use are from the ACTG SF-21 (a modified version of the Medical Outcomes Study instrument).

The overall evaluation objectives are to:

• Describe the change in functional health status for different populations and groups of clients.
• Identify services or constellations of services and intensity of services associated with change in functional health status.
• Assess whether programs meet intermediate objectives (decreased drug use, increased service use, improved housing stability).
• Identify barriers to access to and maintenance in care.

Inclusion Criteria:

• HIV-positive
• Not in HIV care, or difficulty being maintained in HIV care
• HIV-negative but at high risk of HIV infection

Exclusion Criteria:

• HIV-negative and not at high risk of HIV infection