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Empowerment Resource Center submits this grant application for the Integrated Care Partnership (ICP Program) under SAMHSA FY2022 Minority AIDS Initiative—Service Integration (Short Title: MAI-SI) NOFO No. SM-22-005. Under the ICP Program, Empowerment Resource Center (ERC) proposes to provide evidence-based, trauma-informed, and culturally appropriate mental health (MH) therapy and practices for individuals with MH or co-occurring (COD) disorders. ERC will target racial and ethnic minority adults, with or at risk of MH disorders and COD, and residing in the Atlanta metropolitan area, with one of more of the following experiences: self-injurious, suicidal, or risk taking behaviors; housing instability; and/or living with or at high-risk of HIV. The ICP Program will enroll clients based on their membership in the target population and their willingness to voluntarily participate. ERC will provide mental health therapy and resiliency services for 125 unduplicated members of the target population with MH disorders or COD, with a priority focus on African-American and Latino men and women, aged 18 years and older—approximately 5,375 client encounters, annually. Through its CARF-accredited MH and Integrated Outpatient Treatment Alcohol & Other Drugs (AOD) services (AOD/MH) and non-residential Intensive Outpatient Treatment programs, ERC will promote the proposed program, recruit and enroll participants, offer MH services for 500 unduplicated members of racial and ethnic minority groups, over the entire project period—an estimated 21,500 client encounters through September 29, 2026. ICP Program participants will be screened and assessed for MH/COD by licensed, trained, and qualified behavioral health (BH) providers. Upon enrollment, clinicians at the on-site ERC Comprehensive Intervention Clinic will provide rapid HIV testing, screen for TB and viral hepatitis, and link eligible participants to PrEP or long-term HIV/Hepatitis primary care. In-house MH providers will offer group- and individual-level MH therapy and resiliency services for participants, based on their Individual Resiliency and Recovery Plans (IRRP). In addition, the ERC Peer Leader will work with participants to create individualized Wellness Recovery Action Plans and conduct self-help support group sessions designed to develop coping and life management skills. Furthermore, participants will receive case management and resource coordination services that make active referrals to housing, transportation, evidence-based HIV behavioral, biomedical, and structural interventions, and other supportive services. Enrolled participants will also be encouraged to access hepatitis immunization services, HIV/hepatitis primary care linkages, and integrated STI screenings through the ERC clinic, as needed. Through the ICP Program, ERC will: (1) increase the accessibility of HIV and hepatitis prevention services within a BH care setting; (2) provide trauma-informed and culturally-appropriate evidence-based services for individuals with MH/COD; (3) provide peer support services for participants; (4) provide case management services to coordinate BH, primary care, HIV and hepatitis treatment, and supportive services; and (5) implement effective outreach strategies to promote proposed behavioral health services, and HIV and hepatitis primary care and prevention services. ERC, located in Atlanta (Fulton County), GA, is a not-for-profit, community-based organization with a valid IRS 501(C)(3) status. Services will be provided on-site at the ERC Comprehensive Intervention Clinic. Lisa Rudeseal, LPC, MS will serve as the ICP Program Director. ERC is a non-residential outpatient facility and is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) and permitted by the Georgia Department of Community Health, Drug Abuse Treatment and Education Program. Jacqueline Brown is the CEO and will serve as Principle Investigator.

Bailey House, Inc's Project AIM will serve Black and Latinx men and women aged 18 and over in Upper Manhattan and the South Bronx with a Serious Mental Illness (SMI) or Co-occurring Disorder (COD), by utilizing lessons learned from its initial Project AIM award (funded under SM-18-004) to further strengthen hepatitis C (HCV) testing, enhance support groups, and increase its repertoire of evidence-based practices (EBPs). Project AIM will be implemented in Bailey House's Park Avenue Behavioral Health Center in East Harlem and will serve the following geographic catchment areas of New York City (NYC): Central and East Harlem in Upper Manhattan; and Hunts Point/Mount Haven, Highbridge/Morrisania, Crotona Tremont, Hunts Point Mott Haven, and Fordham-Bronx Park in the South Bronx. Nearly 900,00 individuals reside in the service area, many of whom are low-income and are disproportionately impacted by behavioral health disorders. Overall, 55% identify as Hispanic/Latino and 31% identify as Black; just over one-third (35%) of the population is foreign born; and nearly two-thirds (61%) of the service area speak a language other than English at home. Roughly 35% of households in the service area live below the federal poverty level (FPL); and most Bailey House clients live below 100% of the FPL. Residents in the service area also have significantly higher rates of mental illness and substance use compared to NYC. Depression rates in the South Bronx (16.9%) and East Harlem (21.4%) are over twice as high than NYC (8.9%), and drug-related hospitalizations and mortality rates in service area are among the highest in the city. Nearly all service area neighborhoods are designated Health Professional Shortage Areas (HPSA) for primary medical care, mental health care, and dental care, as well as Medically Underserved Areas (MUA). In 2020, the service area accounted for 21.8% of all new NYC HIV diagnoses, with Black and Latinx individuals accounting for 94.1% of those newly diagnosed; the service area neighborhoods also have higher HCV rates than all of NYC, with Morrisania and Crotona having the third highest rates out of all 42 UHF neighborhoods (131.0 per 100,000). BH proposes to serve 295 individuals through increased HCV testing; continued robust case management; expanded recreational and support groups to improve social connectedness among enrolled clients; and an added trauma-informed care approach along with the SAMHSA Anger Management EBP to its existing suite of EBPs which include Screening, Brief Intervention, Referral, and Treatment (SBIRT) with Motivational Interviewing (MI) techniques, Wellness Self-Management Plus (WSM+), Seeking Safety, and Healthy Living Project (HLP). Importantly, BH will integrate Project AIM with the agency's recently awarded NYC Health Department-funded PlaySure Network award, a status-neutral, sex-positive approach to HIV, HCV, and STI testing and linkage to services program. Project AIM's goal is to reduce the incidence of HIV, HCV, and improve overall mental health outcomes for individuals with SMI or COD among the population of focus. By the end of the project, 75% of clients completing Seeking Safety or WSM+ will report increased use of positive coping skills, 75% of clients completing SAMHSA Anger Management will report increased use of anger management skills; and 75% of clients completing HLP will report increased knowledge on sexual risk behaviors. In addition, 75% of enrolled clients will complete at least one behavioral health-related follow-up visit based on recommended services documented at intake; and substance use and symptoms of depression and anxiety by 10%.

Serving Children and Adults in Need Inc. (SCAN) is proposing to implement its Frontera HIV and Mental Health Treatment Expansion Project in Webb County, Texas, located along the Texas-Mexico border. The population of focus is Hispanic females and males 18 years of age and older at high risk for HIV/Hepatitis infection who meet the criteria for a mental health disorder or co-occurring mental health and substance use disorders or co-occurring substance use and mental health disorders (CODs). The project will provide behavioral care to a total of 400 clients using evidence-based practices over the life of the project (100 participants per year). In addition, a total of 800 high-risk individuals and their partners will be tested for HIV and hepatitis and linked to appropriate medical care. The project will implement the following evidence-based practices (EBPs): Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), Seeking Safety, the Cognitive Processing Therapy for PTSD, Integrated Dual Disorder Treatment and RESPECT. These EBP's will be part of a trauma-informed, holistic, and comprehensive approach to care that integrates case management and peer recovery services. The EBPs will address the diverse behavioral needs of the population of focus and will meet the population's linguistic and cultural needs. These evidence-based practices will focus on engagement, retention, and motivation for treatment; mental health; traumatic stress and substance use; co-occurring and mental health and substance use disorders; and HIV/hepatitis prevention. EBPs will be delivered in a continuum of services that integrates the project's resources (behavioral care with HIV and hepatitis testing, hepatitis vaccinations) with medical care and SCAN's other services and the resources in the community. The goals of the project are: 1) Prevent the spread of HIV by providing easily accessible HIV and hepatitis prevention services within a behavioral health care setting. 2) Meet the HIV prevention, mental health treatment and trauma needs of clients by providing culturally-informed evidence-based treatment for individuals with mental health disorders or COD that are trauma-informed, recovery-oriented, and culturally and linguistically congruent. 3) Enhance community awareness about the project by implementing outreach strategies that effectively target the population to inform individuals of available behavioral health services, HIV and hepatitis primary care, and prevention services. 4) Meet the comprehensive needs of the clients by providing case management services to coordinate all aspects of care, including behavioral health, primary care, HIV and hepatitis treatment, other supportive services, and transitions to the community after any hospitalizations or emergency room visit. 5) Maintain Memorandum of Agreement with primary HIV treatment and care providers to strengthen integration of care through case management. 6) Facilitate recovery, foster physical health, and improve clients' lives by demonstrating positive outcomes at discharge and 6-months follow-up based on GPRA data. 7) Collect quality data efficiently and consistently to ensure the best possible clinical outcomes, timely reporting, and program improvement.

Neighborhood House's Community Outreach, Referral and Engagement (CORE) program will provide integrated HIV and viral hepatitis testing and treatment, mental health, substance use disorder, and co-occurring disorder treatment services to Black and Latinx adults age 18+ in Seattle and south King County, WA. King County is one of the localities hardest hit by the HIV epidemic. Our populations of focus and the neighborhoods we are focusing on face behavioral health disparities and lack integrated, culturally appropriate services to address their needs. NH will partner with Public Health Seattle-King County, Hepatitis Education Project, and three behavioral health treatment providers (Navos, Valley Cities, and Sea Mar) to provide integrated and co-located services. Evidence-based practices that we plan to utilize include motivational interviewing, social network strategy for outreach, personalized cognitive counseling, and cognitive behavioral therapy. Our project will serve a total of 600 unduplicated individuals (year 1: 120, year 2: 180, year 3: 180, year 4: 120). We plan to reduce MH and/or COD issues in our population of focus in our area of focus by 10% from baseline; provide an additional 600 instances of equity-based HCV testing, HBV and Hepatitis screening to reduce risks in our population/area of focus; and provide an additional 600 instances of equity-based Rapid HIV counseling, testing and referrals for linkage to care, MH/COD and other services for our population/area of focus.

Connected Care Initiative (CCI) integrates mental health (MH) and co-occurring disorder (COD) treatment with HIV/viral hepatitis (VH) medical care and prevention services, at Positive Impact Health Centers, an AIDS Service Organization with a 30-year history in the Atlanta, GA area. During the four-year project, 376 people living with, and at risk of, HIV, will enroll in evidence-based services, including trauma treatment, psychiatry, case management, and peer support. The majority of consumers will be African Americans who identify as gay men or cis/trans women. The overarching goals of this initiative are to: 1) reduce the incidence of HIV 2) improve health and mental health outcomes for people with MH/COD. These could not be more critical than in Atlanta, where, according to the CDC, HIV is 16 times more prevalent than the US prevalence. Service integration is first key to reaching these goals. CCI implements the evidence-based practice (EBP) of Patient Centered Medical Home (PCMH), a formal care delivery model that provides care to patients when and where they need it, in a manner they can understand. MH/COD providers, primary care providers, and case managers are assigned to Care Teams that meet in daily huddles, and weekly for case consultation, ensuring that care is fully coordinated to meet patient needs. The model also requires non-traditional hours, walk-in services, and 24-hour emergency phone access to providers. The second key is the provision of accessible, evidence-based, culturally appropriate MH/COD treatment. Because people living with HIV experience post-traumatic stress disorder (PTSD) at up to eight times the general population rate, and untreated MH/COD can lead to risk behavior and non-adherence to care, CCI utilizes two EBPs to treat trauma: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR). CCI also provides peer support utilizing the Wellness Recovery Action Plan (WRAP). CCI consumers can access the agency's wrap-around services that include psychiatry, medication co-pay assistance, case management, HIV/VH testing, VH vaccination/treatment, a licensed Intensive Outpatient Substance Abuse Treatment program, and Medication Assisted Treatment for opioid use. The third key is to reach those most at need of services, including the 29% of people living with HIV in Atlanta who are not in HIV care. CCI does this through a successful prevention strategy: geo-fenced social media advertisements that are pushed when people are in specific locations (sex clubs, gay bars, and ballroom scene events). Implementation of these strategies results in more individuals recovering from MH/COD issues, reducing HIV risk behavior and, reducing lapses in care.

Community Rehabilitation Center Project AGAPE ABSTRACT Community Rehabilitation Center (CRC) seeks funding to expand the current treatment delivery model to help reduce the co-occurring epidemics of HIV, Hepatitis, and mental health disorders through accessible, evidence-based, culturally appropriate mental and co-occurring disorder treatment that is integrated with HIV primary care and prevention services. Project AGAPE will specifically target at-risk, minority adult individuals with a mental health disorder or co-occurring disorder (COD). The catchment area is Duval County - one of the localities hardest hit by the HIV epidemic by the Department of Health and Human Services. the rate of white and Hispanics in the area. The following are the proposed measurable goals and objectives: 1) By December 30, 2022, CRC will review and improve current infrastructure, including workforce development necessary for delivering trauma-informed, recovery oriented, and culturally appropriate treatment. 2) By September 2026, Project AGAPE will conduct 2,400 engagement, recruitment, and linkage contacts targeting the population of focus. 3) By September 2026, Project AGAPE will enroll a total of 350 minority participants 4) By September 2026, Project AGAPE will conduct 1,200 HIV and 350 HCV testing sessions 5) By September 2026, Project AGAPE will Provide 350 participants with recovery oriented, trauma-informed, and culturally appropriate mental health and/or co-occurring treatment utilizing evidence-based practices including: Cognitive Behavioral Therapy (CBT), Integrated Treatment (IT), Motivational Interviewing (MI), Seeking Safety. 6) By the end of each contract year, META Consultants will assess program effectiveness and impact in the target population, ensure quality of services provided, identify successes, and implement needed improvements. To achieve the goals and objectives of the program, Project AGAPE's staffing plan will include a Clinical Director, Project Director, Licensed Mental Health Counselor, Case Manager, Certified Recovery Peer Support Specialist, and Evaluator

Established in 1972, The San Diego Lesbian, Gay, Bisexual, and Transgender Community Center (The Center) is one of the most vibrant and largest LGBT community centers in the nation. The mission is to enhance and sustain the health & well-being of the lesbian, gay, bisexual, queer, transgender, nonbinary, immigrant, and HIV communities to the betterment of our entire San Diego region. The Center's Minority AIDS Initiative Service Integration (MAI-SI) program will provide services for target population of focus San Diego County (SDC) individuals ages 18 and over, of racial and ethnic minorities, have a mental health disorder and/or co-occurring disorder, and are living with or at risk for HIV and/or hepatitis. This specifically includes men who have sex with men (MSM) and transgender women who are Black/African American, Hispanic/Latinx, Indigenous, Alaska Native, Native Hawaiian, and Asian/Pacific Islander population. Services will be delivered in the geographic catchment area of SDC. The Goals are: (1) Increase The Center's capacity to provide integrated services that will help reduce the co-occurring epidemics of HIV, hepatitis, and mental health disorders among members of the population of focus; (2) Identify and enroll members of the population of focus in integrated services to help reduce the mental; (3) Implement four evidence-based practices (EBPs): trauma-informed care (TI), motivational interviewing (MI), personal cognitive counseling (PCC), and PrEP. The Center's MAI-SI program will use four evidence-based practices (EBP), two are from SAMHSA Evidence-Based Practice Resource Center: (1) trauma-informed care (TIC); and (2) motivational interviewing (MI). The other two EBP's are: (3) personalized cognitive counseling (PCC), and (4) PrEP. All chosen EBPs are appropriate for the LGBTQ population and services provided under the proposed program. No adaptations to EBPs will be made. Lastly, we will serve 700 people over the lifetime of the project, and 200 unduplicated people each year from Year 2 to Year 4, with year one we are serving 100 prorated for a 4-month program set up.

FoundCare OneStop Care Project During the four-year SAMHSA MAI-SI grant period FoundCare's OneStop Care project will increase access to integrated care for 1,500 unduplicated Black/African American and Hispanic/Latino adults in Palm Beach County (PBC), Florida with a mental health disorder or co-occurring disorder who are living with or at risk for HIV and/or hepatitis. Each year of the project, OneStop Care will serve 250 of these individuals with culturally relevant and Trauma-Informed screening, assessment, treatment, case management, and recovery support services. PBC is among 50 identified localities in the U.S. that has been hardest hit by the HIV epidemic. OneStop Care will integrate several strategies using various evidence-based practices and internal FoundCare departments to provide services. Strategies include information systems upgrades, targeted outreach, brief screening techniques to assess service needs, assessment to individualize treatment, treatment for mental health/primary care/substance use, and Trauma-Informed (TI) case management and recovery services. Below are the anticipated goals and objectives the OneStop project will meet during the grant period. Table 3. Goals & Objectives Goals Objectives Goal 1: Provide integrated care to B/AA & H/L adults for behavioral health, HIV and hepatitis primary care, and prevention services in PBC. 1A. By the end of the 4-yr. grant period, OneStop Care will provide 1,500 B/AA and H/L adults with integrated TI care for behavioral health, HIV/hepatitis primary care, and prevention services. 1B. By the end of the 1st grant year, Foundcare will complete an information systems upgrade to enhance existing infrastructure and produce integrated efficiencies across all programs. Goal 2: Increase awareness of behavioral health care for B/AA & H/L adults in Palm Beach County at risk for HIV/hepatitis. 2A. By the end of the 4-yr. grant period, OneStop Care will participate in 20 outreach events at local hospitals, primary care providers, & community events to increase awareness of project services in communities of color. 2B. By the end of the 4-yr. grant period, OneStop Care will contact 10k individuals through outreach activities & disseminate oral/written information about MH/COD/HIV/Hep. Goal 3. Increase access to integrated behavioral health, HIV and hepatitis primary care, and prevention services for B/AA and H/L adults in Palm Beach County. 3A. By the end of the 1st grant yr., OneStop Care will translate all program materials to Spanish and Haitian Creole. 3B. By the end of the 4-yr. grant period, OneStop Care will provide 1,500 B/AA and H/L adults with screening and rapid testing for behavioral health and HIV/hepatitis diagnosis. Goal 4: Decrease behavioral health disparities in Palm Beach County. 4A. By the end of the four-yr. grant period, OneStop Care will provide TI behavioral health services to 70% of B/AA and H/L adults at risk for or diagnosed with HIV/Hep that also screen as positive for a mental health and/or substance use diagnosis. 4B. By the end of the 4-yr. grant period, 80% of adults with co-occurring MH/COD/HIV/Hep diagnosis will increase their recovery capital score by 5-points on the Recovery Capital Index tool. 1 Centers for Disease Control and Prevention, Combined HIV Diagnoses for 2016-2017.(2018).

Detroit Recovery Project (DRP) is located in Detroit, where it provides substance use disorder treatment and prevention services to Detroit, Highland Park, and Hamtramck residents. DRP has provided services to this tri-city area for over 15 years. The tri-city area is the most populated area of Michigan. It is also the most impoverished, and most likely to experience health disparities. n Detroit Persons Living with HIV (PLWH) is 3.5-fold that of the next highest county.9 In 2018 there were 787 new incidences of HIV and a prevalence rate of 683.1 per 100,000.9,10 Highland Park has the highest HIV prevalence rate in Michigan at 1844.0 per 100,000, and an unsuppressed rate for HIV of 40-54%.9,11 DRP is proposing a new project REDI (Removing barriers, Engagement in care, Decreasing HIV, Increasing access to recovery and care). The purpose of REDI is to increase the number of racial/ethnic minorities that identify as People Who Use Drugs (PWUD) engagement in SUD/COD care for those are at risk for HIV or living with HIV and to decrease new cases of HIV in the Detroit, Highland and Hamtramck area. Five Goals have been identified to achieve this purpose and are in line with the CDC's Ending the HIV Epidemic (EHE). The goals of this project are: Goal 1: Increase the number of individuals that know their HIV and HCV status among racial/ethnic minorities that identify as People Who Use Drugs (PWUD). Goal 2: Decrease new HIV and HCV cases among racial/ethnic minorities that identify as People Who Use Drugs (PWUD). Goal 3: Increase Linkage to Care for HIV positive individuals. Goal 4: Increase Linkage to Treatment for HCV positive individuals. Goal 5: Remove barriers among racial/ethnic minority individuals accessing SUD Increase access to HIV, HCV, and STI treatment. DRP's REDI will build and maintain relationships with other community providers to address the needs of this population. REDI will also do so using evidence-based practices (ARTAS, POL, SNS), and Peer based services. Over the life of the grant REDI will serve 350 individuals.

ABSTRACT Summary. Abounding Prosperity, Inc. (AP, Inc.) is proposing a program to increase access to mental and co-occurring disorder treatment services that are integrated with HIV primary care and prevention services. The population of focus will be persons with a mental health disorder or COD living with or at risk for HIV and/or hepatitis, in Dallas County, TX. AP, Inc. will serve 120 unduplicated individuals annually and 480 over the entire project period. Project name. Dallas COD-HIV Program Populations to be served. The populations of focus (POF) will be individuals, ages 18 and over, of racial and ethnic minorities (primarily black/African American, Hispanic/Latino) with a mental health disorder or co-occurring disorder (COD) living with or at risk for HIV and/or hepatitis; AP, Inc. will focus the program on men who have sex with men (MSM) and transgender women in particular who have co-occurring disorders of HIV, mental health and substance use. The geographic catchment area where services will be delivered is Dallas County, TX. Strategies/interventions. Program activities will include: 1) HIV and hepatitis prevention services (e.g., screening, risk assessment, prevention counseling, HIV and hepatitis testing, referral to pre- exposure prophylaxis (PrEP), hepatitis vaccination) within a behavioral health care setting; HIV and hepatitis testing will also be provided during outreach activities; 2) provide culturally-informed evidence-based treatment and practices for individuals with mental health disorders or COD that are trauma-informed, recovery-oriented, and culturally appropriate; 3) provide peer support services, including accompaniment and navigation, appointment scheduling assistance, ongoing peer support and mentoring through group and individual activities, and coordination of care within AP, Inc. and with external providers; 4) implement outreach strategies; 5) provide case management services to coordinate all aspects of care, including behavioral health, primary care, HIV and hepatitis treatment, other supportive services (e.g., housing, benefits, employment), and transitions to the community after any hospitalization or emergency room visit; 6) develop additional MOAs with HIV care providers, hepatitis B and C treatment providers, and primary care providers and 7) infrastructure development activities to enhance its EHR and training/workforce development to provide trauma-informed care; AP, Inc. will implement the following EBPs: Personalized Cognitive Counseling (PCC) and Motivational Interviewing (MI). Project goals and measurable objectives. The program's goal is to increase access to evidence-based, culturally appropriate mental and co-occurring disorder treatment services that are integrated with HIV primary care and prevention services. The program's objectives are to: Conduct outreach and recruitment activities, reaching at least 800 persons from the POF per year; Provide HIV and hepatitis screening, risk assessment, prevention counseling, and HIV and hepatitis testing to 120 members of the POF per year; Provide culturally-informed evidence-based treatment and practices for 100 enrolled individuals with COD per year; Provide peer support services for 100 enrolled participants per year; Provide case management services to 100 enrolled participants per year; and Provide referrals for HIV treatment, hepatitis treatment and PrEP services to at least 95% of enrolled participants in need of referrals per year.

The State University of New York (SUNY) Downstate Health Sciences University (DHSU) proposes to conduct the STAR Health Center Integrated Care Project. The project will be implemented by the Special Treatment and Research (STAR) Program at both sites of the STAR Health Center, the STAR Program's trauma-informed, co-located outpatient primary care and behavioral health program for adults, ages 18 and older. The SHC's flagship site (STAR-Downstate) is located in Suite J of SUNY-DHSU's University Hospital of Downstate in East Flatbush. The SHC's second outpatient site, STAR-Brookdale, is located at One Brooklyn Health-Brookdale Hospital Medical Center in East NY. This area is underserved with respect to primary and mental health care and is disproportionately affected by HIV. The populations of focus, Black and Latinx adults with symptoms of mental illness, serious mental illness (SMI) or co-occurring disorders (COD), living with or at risk for HIV and/or hepatitis, have complex health care and treatment needs. SUNY-DHSU and Brookdale serve a densely populated urban service area populated by predominantly Black (over 75 percent) and Latinx (over 20 percent) populations. Barriers to care include poverty, homelessness, unemployment, and lack of education and/or health insurance. Brooklyn ranks first in NYC for new HIV diagnoses, AIDS diagnoses, and concurrent HIV/AIDS diagnoses. Nearly 12.4 percent of Brooklyn's cumulative AIDS cases among women are attributable to injection drug use; 10 percent among men. Proposed interventions include in reach and outreach to inform individuals of available HIV, hepatitis and mental health prevention and treatment services, providing evidence-based mental health and substance use disorder treatment and practices that are trauma informed and recovery oriented, such as Motivational Interviewing and Cognitive Behavioral Therapy, rapid HIV and HCV screening and hepatitis A and B vaccinations, PEP/PrEP, comprehensive interdisciplinary on site HIV, hepatitis and mental health care, peer support services, and case management. Goals include identifying adults experiencing symptoms of mental illness, SMI or COD living with or at risk for HIV and/or hepatitis, implement evidence based interventions, provide HIV and hepatitis screening and hepatitis vaccinations, and engage those testing positive for HIV and/or hepatitis and/or SUD/COD to primary care and behavioral health care services at the SHC. Objectives include providing in reach and outreach to identify eligible clients, HIV and hepatitis prevention services and linkage to primary care, peer support and case management for 100 percent of newly identified positives. The project will serve 50 clients in Year 1, 100 each in Years 2 and 3, and 50 clients in Year 4 for a total of 300 clients.

La Casa de Salud, Inc. (LCDS) is an independent 501(c)(3) corporation and a New York State (NYS) Article 28 Diagnostic & Treatment Center. It has been serving the South Bronx community since 1998 and has been a Federally Qualified Health Care Center (FQHC) Health Care for the Homeless (HCH) program since 2009. LCDS has three health centers in the South Bronx, serving residents of the underserved and high-need South Bronx communities of Hunts Point Mott Haven (zip codes: 10454, 10455, 10459, 10474) and Highbridge Morrisania (10451). - LCDS Health Center located at 966 Prospect Avenue (established in 1998, FQHC 0-designated in 2009); - Ramon Velez Health Center (RVHC) located at 754 East 151st Street (added in 2015); - Casa Maria Health Center (Casa Maria) located at 324 East 149th Street (added in 2017) Since 1998, LCDS has been operating a continuum of primary care, specialty, behavioral health, and wraparound support services programs to address the needs of underserved New Yorkers, with expertise in engaging people living with HIV (PLWH), substance users, individuals with mental health conditions, and persons experiencing homelessness. Its integrated clinical staffing team provides an array of primary care, dental, pediatric, mental health care, substance use treatment, case management, and enabling services. La Casa de Salud, Inc. will provide accessible, evidence-based, culturally appropriate mental and co-occurring disorder treatment that is integrated with HIV primary care and prevention services to individuals, ages 18 and over, living with or at risk for HIV and/or hepatitis, with a particular focus on Hispanic/Latino and African American residents in the Bronx. LCDS will partner with three other affiliates of the Acacia Network, who serve a large volume of residents/clients with mental health and co-occurring disorders, including: Promesa, Inc. Community Residences (CRs) and Certified Community Behavioral Health Clinics (CCBHC), United Bronx Parents, Inc. HIV Health Homes (HH) and Chemical Dependence Program, and Community Association of Progressive Dominicans (ACDP) Outpatient Clinic Treatment Program Over the four-year program, in collaboration with these partners, LCDS will achieve the following: Objective 1: By the end of the program, implement outreach strategies and provide prevention education to 400 individuals per year, or a total of 1,600 by the end of the four-year period. Objective 2: By the end of the program, provide HIV/HEPC C/Mental Health Screenings to 50% of the individuals identified via outreach. Objective 3: By the end of the program, enroll 100% of individuals screened for HIV/HCV/MH into the program Objective 4: By the end of the program, develop a care plan for 80% of clients to address medical, MH, and SUD needs. Objective 5: By the end of the program, provide prevention, treatment, peer support and case management services to 100% enrolled clients as aligned to their care plan. By the end of the program, 25% of clients will report a reduction in anxiety or depressive symptoms from baseline.

Summary. Metropolitan Charities, Inc. (d.b.a. Metro Inclusive Health, Inc., referred to as METRO hereafter), an accredited behavioral health and HIV medical provider with 29 years of experience and a proven track record of effectively serving the population of focus will implement the Minority AIDS Initiative Service Integration program to expand and enhance accessible, evidence-based, culturally appropriate mental health and COD treatment that is integrated with HIV primary care and prevention services to help reduce the co-occurring epidemics of HIV, Hepatitis, and mental health disorders, reduce incidences of HIV and improve overall health outcomes for at-risk racial, ethnic minorities with a MH/COD. Project Name: Minority AIDS Initiative Service Integration. Population(s) to be served: Adults (ages 18+) diagnosed with a mental health disorder or co-occurring disorder (COD) based on ASAM placement criteria; 69% Male (MSM); 30% Female; 1% Transgender; 80% African American; 15% Hispanic/Latinx; 5% Multiracial; and 6% LGBTQ+; living with or at risk for HIV and/or hepatitis residing in Hillsborough and Pinellas counties. Interventions: 1) Provide easily accessible HIV and Hepatitis prevention services (e.g., screening, risk assessment, prevention counseling, HIV and hepatitis testing, referral to pre-exposure prophylaxis (PrEP), hepatitis vaccination) within METRO's behavioral health care setting; 2) Provide culturally-informed evidence-based treatment and practices for individuals with MH or COD that are trauma-informed, recovery-oriented, and culturally appropriate; 3) Provide peer support services for individuals with MH/COD; 4) Implement outreach strategies that effectively target the populations of focus and inform of service integration in community and using social marketing; 5) Provide case management and care coordination to coordinate all levels of care, including behavioral health, primary care, HIV and hepatitis treatment and supportive services (housing, benefits, employment), including transitions to the community following inpatient hospitalization or ER visits; and 6) Develop seamless service integration coordinating the following care on-site at METRO: (a) Primary HIV treatment and care, including Ryan White services; (b) Referrals and linkages to follow-up care and treatment for individuals with viral hepatitis (B or C); (c) Referrals and linkages to PrEP; and (d) Referrals and linkages to primary care services. EBPs: Trauma-informed MH/COD standardized screening/assessment (AUDIT, CAGE-AID, PHQ-9, GAD-7, Trauma Symptom Checklist 40); MI; Strengths-based CM; TF-CBT; EMDR; Affirmative Therapy; WRAP; 3MV; and HIV Navigation Services. Goals: 1) Expand access to HIV and hepatitis prevention services (e.g., screening, risk assessment, prevention counseling, HIV and hepatitis testing, referral to pre-exposure prophylaxis (PrEP), hepatitis vaccination); 2) Expand access and increase HIV and hepatitis testing on-site in racial and ethnic high-risk communities; 3) Reduce behavioral health disparities and improve mental health functioning with expanded access to culturally-informed evidence-based treatment that is trauma-informed, recovery-oriented, and culturally appropriate; 4) Facilitate peer support services. Measurable Objectives: 1) 80% will improve mental health functioning; 2) 80% will reduce trauma symptoms/violence; 3) 80% will improve stability in housing; 4) 80% will improve education/employment status; 5) 80% will reduce CJ involvement; 6) 80% will report high perceptions of care; 7) 80% will improve social connectedness, and 100% will receive HIV-specific measures. # to be served: 65 unduplicated individuals each year, totaling 260 in four years.

In collaboration with the Lyon Martin Health Services (LMHS), the Trans Wellness Service Integration (TWSI) project as part of the Health Intervention Projects for Underserved Populations (HIPUP), Public Health Institute (PHI) aims to implement HIV, substance abuse, and mental health prevention and treatment programs for gender non-binary people (GNBP) in Alameda and San Francisco Counties, California. TWSI interventions will be based on EBPs: Motivational Enhancement Intervention (MEI) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Through direct and online outreach, we will recruit high risk GNBP adults including transwomen, transmen, and gender non-binary people and provide intake assessment, HIV/Hep testing, and referrals for prevention (e.g., PrEP and vaccination) and treatment (ART) at LMHS. Peer Counselors will work with clients to reduce HIV risk and substance use behaviors and promote mental health and access to GNBP support services [e.g., Stable Housing and Employment (SHE)] based on MEI and Peer Support Groups. After completing MEI sessions, clients who do not show improvement will be referred to Professional Counseling based on MEI and/or TF-CBT. We will provide comprehensive referral and navigation services for HIV/Hep treatment and other health and social services that are sensitive to GNBP. Also, we will disseminate project activities and findings through our project website and SNS to increase awareness and knowledge for HIV and substance abuse prevention and treatment and mental health promotion for GNBP. We will attain the following measurable objectives: 1) Develop and complete 12 Memorandum of Agreements (MOAs) with collaborating service agencies; 2) Establish the Community Advisory Board (CAB) and meet quarterly; 3) Conduct community- and online outreach and make 5,250 contacts with high-risk GNBP in Alameda and San Francisco counties; 4) Screen eligibility for 3,150 GNBP and provide referrals for prevention and treatment; 5) Enroll 420 GNBP into TWSI, conduct intake assessment, and HIV and Hep testing; 6) Provide all 420 clients with Peer Counseling/Case Management; 7) Enroll 42 newly diagnosed HIV clients or those dropped out into HIV primary care; 8) Enroll 140 clients into PrEP; 9) Screen for substance use and mental health disorders for 210 clients; 10) Enroll 106 clients into Professional Counseling; 11) 110 clients enroll in Peer Support Groups; 12) 378 clients complete Peer/Professional Counseling and the exit interview; 13) 336 clients (80%) complete the 6-month follow-up assessment; 14) Conduct 48 process evaluation; 15) Conduct 4 outcome evaluation; 16) 210 clients significantly reduce HIV risk and/or substance use behaviors and/or mental health problems at 6-month follow-up compared with the intake assessment; 17) Disseminate project findings and experience through 8 community forums and online (2,250 clicks on our project website or positing on SNS). TWST is an ideal expansion and enhancement of our current services for GNBP who are struggling with HIV/AIDS, substance use, and mental health problems and a lack of coordination of these vital prevention and treatment services.

Project Abstract Tarzana Treatment Centers, Inc. (TTC) will strengthen and enhance its integrated, whole-person system of care and prevention services for individuals with mental health or co-occurring mental health and substance use disorders (CODs) who are living with or at risk for HIV and Hepatitis in Los Angeles County (LAC). TTC's Whole Health Integration Project Plus Social Networking Strategy (WHIP+SNS) will target men who have sex with men (MSM), people who inject drugs (PWID), and others at risk for HIV/Hepatitis, with a focus on racial/ethnic minorities. LAC has the second largest number of persons living with diagnosed HIV (PLWDH) in the U.S. and minorities are at greatest risk with an incidence rate of 39 (per 100,000) for Black and 14 for Latinx compared to 10 for Whites (2019). Among LAC National HIV Behavioral Surveillance (NHBS) respondents, HIV positivity was highest for Black MSM at 36% followed by Latinx MSM at 18% and White MSM at 15%. White MSM had higher levels of testing than Latinx and Black MSM (83%), and White MSM participants were more likely to have used PrEP consistently for 2 or more months in the past year than Black or Latinx MSM participants. Viral suppression was also lower for Blacks and Latinx compared to Whites. Limited access to care seems to be driving these disparities with a higher proportion of minorities experiencing HIV service gaps. An even high proportion of PLWDH with a history of mental illness or recent substance use experienced service gaps. TTC has long sought to address the complex needs of the target population by co-locating an integrating behavioral health services with HIV services. However, funding for outreach services has been limited, so marginalized individuals at highest risk are not being reached. As one of the largest behavioral health agencies in LAC, TTC will identify and engage participants through implementation of an innovative community-based social networking strategy in conjunction with in-reach at TTC's substance use disorder (SUD) treatment and mental health services programs, Syringe Exchange Program, and HIV Specialty Care/PrEP Clinic. The overall aim of TTC's WHIP+SNS is to expand access to fully integrated evidence-based, culturally competent behavioral health services and HIV/Hepatitis testing and care/prevention services for those most at risk for HIV/Hepatitis in LAC. The project will address the identified disparities (higher infection rates among racial/ethnic minorities) and service gaps (lack of coordinated case management to assist individuals with mental illness or COD and limited funding for outreach services to reach marginalized individuals) leading to a reduction in the incidence of HIV and Hepatitis and improved health outcomes for the target population. In order to accomplish this, WHIP+SNS will: 1) identify the target population through implementation of an innovative evidence-supported outreach and engagement practice called Social Network Strategy (SNS) as well as in-reach at TTC service sites; 2) provide HIV/Hepatitis prevention services, including screening, risk assessment, prevention counseling, HIV/Hepatitis testing, referral to pre-exposure prophylaxis (PrEP) and hepatitis vaccination within a behavioral healthcare setting; 3) screen and assess all participants for mental health disorders or COD and provide them with culturally- and trauma-informed behavioral healthcare services; 4) provide referral and linkage services through enhanced patient navigation and case management to a full continuum of services offered on site at TTC, including primary HIV/Hepatitis treatment and care and PrEP services; and 5) offer peer support groups utilizing Whole Health Action Management (WHAM). TTC will serve a minimum of 75 unduplicated individuals in Year 1 and 80 annually in Years 2-4 for a total of 315 unduplicated individuals served.

Odyssey House Louisiana (OHL) proposes to implement the Minority AIDS Initiative Service Integration project to help reduce the co-occurring epidemics of HIV, Hepatitis, and mental health disorders. Over the four-year grant period, OHL will provide 400 individuals of racial and ethnic minority identities with comprehensive, evidence-based services such as HIV/Hepatitis testing, treatment, and prevention education, case management, safer sex education, cognitive behavioral therapy, and peer support services. This grant will allow OHL to enhance services in an eight-parish (Orleans, St. Bernard, St. Tammany, St. John the Baptist, St. Charles, Jefferson, Tangipahoa, Plaquemines) catchment area to increase the total number of individuals receiving integrated HIV and mental and behavioral healthcare. Funding will be used to increase organized capacity for HIV, hepatitis, and mental and behavioral health services and coordination of medical, behavioral, social, and recovery support services in order to produce better overall health outcomes for New Orleans area individuals who have multiple healthcare needs. The proposed project activities would increase OHL's capacity by hiring a Project Coordinator to create educational interventions on harm reduction and safer sex; two Peer Support Specialists to provide clients with essential one-on-one support services; and, two Service Integration Specialists to assist program participants with connection to wraparound medical care, treatment and recovery support services. These staff members will work closely with OHL's counselors and case managers to ensure that all clients are connected to all appropriate services within OHL's system and linked to outside care if necessary. The project will use data-driven decision-making and evidence-based assessments to develop, implement, and evaluate effectiveness of treatment. With implementation of this grant, the agency will continuously improve its system for treatment of this region's residents. The MAI project from OHL leverages the agency's existing HIV/AIDS, hepatitis, and mental and behavioral healthcare and wraparound services to care for underserved, high-risk patients across southern Louisiana. Integrated behavioral health, primary care, and social services allow patients to take charge of all aspects of their health.

Project Title: CrescentCare Minority AIDS Initiative Service Integration Applicant Organization Name: NO/AIDS Task Force dba CrescentCare Address: 1631 Elysian Fields Avenue New Orleans, 70117 PI Name: Lucy Cordts, Director of Behavioral Health Phone: 504-821-2601 Fax: 504-662-1686 email: lucy.cordts@crescentcare.org website: www.crescentcare.org The purpose of the proposed project is to reduce the co-occurring epidemics of HIV, Hepatitis, and mental health disorders through accessible, evidence-based, culturally appropriate mental health and co-occurring disorders treatment that is integrated with HIV primary care and prevention services. CrescentCare proposes to expand and enhance trauma-informed SUD and/or COD treatment coupled with strength-based case management, behavioral health, HIV and viral hepatitis services for high risk populations, with a focus on individuals, ages 18 and over, of racial and ethnic minorities with a mental health disorder or COD living with or at risk for HIV and/or hepatitis. The project will serve Orleans Parish in Louisiana (encompassing the City of New Orleans) which is one of the localities hardest hit by the HIV epidemic and which qualifies the proposal for the priority points. The population of focus is individuals, ages 18 and over, of racial and ethnic minorities with a mental health disorder or co-occurring disorder (COD) living with or at risk for HIV and/or hepatitis (HCV) in the greater New Orleans area. These at-risk populations are disproportionately impacted by HIV and HCV, particularly among the African American community in New Orleans. Goals for the project are to: Increase engagement in care and retention in care for high risk populations living with HIV; Reduce the negative impact of behavioral health problems and substance use through increased access to and retention in treatment for behavioral health and substance use conditions for individuals in high risk populations living with HIV; Reduce the risk of HIV and HCV for high risk populations through outreach and education services; Reduce new HIV and viral hepatitis infections by increasing HIV and viral hepatitis testing and diagnosis; and Improve service integration between outreach and prevention/education, testing, and linkage to primary and infectious disease care, behavioral health and substance use services, HIV care, and HCV care. The project will serve 50 individuals per year, totaling 250 over the five-year project period and will provide outreach/testing services to an additional 100 individuals each year.

Project HARP's purpose is to enhance and increase access to recovery-oriented, trauma-informed, equity-based, and culturally appropriate mental or co-occurring disorders services for racial/ethnic minority adults, at risk or living with HIV/Hepatitis. Project HARP will help reduce the co-occurring epidemics of HIV, Hepatitis, and mental health disorders through accessible, evidence-based, culturally appropriate mental and co-occurring disorder treatment that is integrated with HIV primary/medical care and prevention services. As an established Federally Qualified Health Center (FQHC) in the area, SHR offers general integrated and collocated behavioral and medical care. SHR seeks to increase access to racial/ethnic minorities primary African American and Latinx - and enhance services with culturally specific, evidence-based, interventions. Participants will receive the following services: outreach/recruitment activities, HIV/Hepatitis testing and prevention services, evidence-based trauma-informed mental and substance use disorder treatment, recovery-oriented peer support, and case management to link, assess, and coordinate all services. As a Federally Qualified Health Center, SHR's compendium of services include a collocated Primary HIV and primary care treatment clinic, state-funded PrEP program, and is the only Ryan White provider in the target area, making referrals and linkages to these programs a fast and seamless process. The following are the proposed measurable goals and objectives: 1) By December 30, 2022, SHR will review and improve current infrastructure, including workforce development necessary for delivering trauma-informed, recovery oriented, and culturally appropriate treatment. 2) By September 2026, Project HARP will conduct 2,400 (50-monthly) engagement, recruitment, and linkage contacts targeting the population of focus. 3) By September 2026, Project HARP will enroll a total of 350 minority participants into the new model of care to receive integrated behavioral health, prevention, and HIV medical care. 4) By September 2026, Project HARP will conduct 1,200 HIV and 350 HCV testing sessions following the Texas Department of State Health Services Foundations of Testing and Navigation (FTN) standards and implementing ARTAS to facilitate linkage to medical care for those testing HIV/HCV Positive through their existing Ryan White Services and Community Health Clinic. To fulfill the purpose of the grant, SHR will assign/hire experienced and competent staff that includes a Clinical Director, Project Director, Project Coordinator, Licensed Professional Counselor, a Case Manager, a Peer Support Specialist, and an Evaluator.

LifeLong Medical Care proposes to increase engagement in care to a minimum of 138 individuals within the population of focus, which includes individuals, ages 18 and over, of racial and ethnic minorities with a mental health disorder or co-occurring disorder (MH/COD) living with or at risk for HIV and/or hepatitis. Services will be provided at LifeLong's East Oakland and Ashby Clinics in Alameda County, CA. The program will hire a licensed/registered mental health clinician as the Project Director to oversee the program and to provide MH/COD services. The program will hire two certified/registered Recovery Support Counselors to provide counseling, coaching, and peer support to participants in the program. The program will hire a Community Health Worker who will assist the Recovery Support Counselors in providing case management services, patient navigation, and recovery support services to individuals at the Clinics. LifeLong will use the Evidence-Based Practices (EBPs) of Harm Reduction, Motivational Interviewing, Seeking Safety, and Contingency Management in its service delivery. Goals include: Enhancing MH/COD treatment services including case management and recovery support services; offering HIV/Hepatitis prevention services including screening, case management, and referrals/linkages to care; implementing outreach activities to re-engage patients into care; conducting local performance assessments and documentation according to grant requirements and guidelines. Objectives include: - MH/COD screening and assessment, and provision of evidence-based MH/COD services including individual and group counseling to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1) - Providing access to case management services including benefits counseling, food assistance, housing, and referrals for additional treatment as needed, such as Medication Assisted Treatment to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1) - Providing access to recovery support services including employment and transportation to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1) - Providing HIV/Hepatitis screening to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1) - Providing all enrolled patients who have a preliminary positive HIV and confirmatory HIV test with case management, referrals/linkages to primary care within the LifeLong Clinics - Offering all enrolled patients who screen negative for HIV and are at risk for becoming infected with HIV access to HIV prevention education, case management, and referral/linkages to onsite PrEP services - Linking all enrolled patients who test positive for viral hepatitis to healthcare within the two LifeLong Clinics; offering patients who are non-immune to hepatitis A and/or B access to hepatitis vaccines. - Creating and distributing fliers and posters to LifeLong clinics and the community and facilitating learning groups to re-engage patients who are not actively engaged in treatment - Participating in cross-site evaluation activities, completing health disparities statement, uploading GPRA data, participating in evaluation activities, and compiling data for semi-annual reports