• Capitated Care. Five of the projects share, as a central theme, the study of the health care provided to individuals with HIV disease under models where the health care is capitated, or paid on a "flat fee" basis per patient per month. The Capitated Care projects differ in the ways that they provide health care, ranging from a community-based clinic (East Boston Neighborhood Health Center) to a large "chain" of community-based clinics (AIDS Healthcare Foundation) to a home-based hospice (Visiting Nurse Association of Los Angeles) to university-based clinics (Johns Hopkins University School of Medicine) to a state-wide system (New York State Department of Health/Health Research). Each project shares the goals of determining costs for providing health care services to HIV/AIDS patients under a capitated care system and of ensuring that high quality care is provided under such a system. As a group, the models and their implementation are quite different from one another; taken collectively, the experiences should serve to define those instances in which a capitated care system for the provision of HIV/AIDS-related services is appropriate and those conditions in which it is not.
• Community-Based Organization (CBO) Models. Six projects share, as a central theme, the goal of providing high-quality care for individuals with HIV who belong to groups that are traditionally underserved because of linguistic, cultural, racial, and economic barriers that prevent their full integration into the traditional hospital-based service system. Outreach, Inc., has implemented a program wherein substance abusers, many of whom are African Americans living in public housing projects, are offered a number of social services to link them to the traditional care system. PROTOTYPES has implemented a "Settlement House model" wherein women with HIV come with their children and receive a number of social services as well as linkages to medical services. If appropriate, substance abusers with HIV are enrolled in a residential treatment program. The Well-Being Institute has developed a three-tier program wherein substance abusing women with HIV are offered the opportunity to receive health, social and support services well before such time as they decide to stop using drugs, and are later offered the opportunity to participate in a 60-day drug treatment program combined with housing in a drug-free environment. Finally, when they have been enrolled and retained successfully in primary care and have stopped using drugs, the women work together in a revenue-generating, entrepreneurial activity, making and selling crafts. The Center for Community Health, Education, and Research/Haitian Community AIDS Outreach Project (CCHER/HAP) provides case management and other culturally-appropriate social services to individuals with HIV in the large Haitian community of greater Boston. CCHER/HAP is a unique hospital and community-based model of case management which blends services from two fronts to better serve Haitians with HIV. The Fortune Society targets Latinos with HIV who are in prison and offers a combination of educational programs, social support, and legal assistance services both while the client is in prison and after release. Larkin Street Services has developed a comprehensive continuum of services for homeless youth living with HIV in San Francisco which includes psychosocial support, medical care, educational and vocational services, and housing. Common to all of the CBO programs is the development of alternate models of care specifically targeted to individuals who have traditionally been underserved. In all of these models, services are provided by a combination of professional staff and "paraprofessional" or "recovering" staff who share many of the same demographic and experiential characteristics of the target clients.
• Comprehensive Healthcare. Three projects are developing specialized medical care models within the context of a continuum of services in a medical clinic. The University of Vermont & State Agricultural College has developed three community clinics throughout Vermont to assess a model of comprehensive HIV care in a rural area. The University of Nevada School of Medicine has added a nutrition component to its comprehensive AIDS care clinic and is studying the effects of adding nutrition assessment, objective measurements, counseling, and supplements to the treatment of wasting in AIDS patients. Both the University of Vermont & State Agricultural College and the University of Nevada projects are providing services to largely rural patient populations. The Washington University project in St. Louis, Missouri is providing a continuum of care to women with HIV and their children within a traditional medical clinic model combined with aggressive community outreach and case management. The Washington University project serves a group of inner city women, most of whom are African American.
• Infrastructure-Advocacy. Projects in the Infrastructure-Advocacy group aim to increase the capacity of local health and social support service systems to provide appropriate, quality services for individuals with HIV. The projects in this group are using methods of service systems development through training and technical assistance to change the service provider infrastructure as well as the community context in which these services are delivered. The Center for Women Policy Studies, through the Metro DC Collaborative for Women with HIV/AIDS (with PROTOTYPES), is increasing the ability of service providers in the metropolitan District of Columbia area to provide services to women with HIV through leadership development with HIV-positive women, policy change, needs assessment, and appropriately-targeted training. Health Initiatives for Youth has developed a media, training, and technical assistance center to promote youth-appropriate and youth-friendly HIV services. The Michigan Protection and Advocacy Service provides training and technical assistance to consumers and service providers regarding HIV legal issues in the areas of employment, confidentiality, health care, accessing social security, and public policy. The Indiana Community AIDS Action Network provides legal assistance to individual clients to redress discriminatory practices by health care providers, employers and others. In addition, this project provides training in legal rights, advocacy skills building, grassroots organizing and public policy advocacy. The Hektoen Institute for Medical Research at the Cook County Hospital’s HIV Primary Care Center/Women and Children HIV Program is increasing the ability of the service infrastructure to provide early identification and linkage into care of women with HIV by training maternal and child health providers on how to provide HIV education counseling and testing by consent. This project is also educating providers on the use of zidovudine to reduce perinatal transmission of HIV. The State University of New York – Health Science Center at Brooklyn is developing systems to support and encourage women to be tested for HIV, especially during pregnancy. If positive, women are routed to appropriate medical services. These services include strategies to reduce perinatal transmission as well as on-going HIV primary and gynecologic care. Training and technical assistance to private providers is a major component of systems change necessary to the Brooklyn project. The University of Texas Health Science Center at San Antonio is developing a model wherein local service agencies and consumers learn strategies for developing comprehensive models of care for women with HIV and their children. The model is a combination of infrastructure development and training. The Missouri Department of Health, through training and agency development strategies, is systematically developing the capacity of Missouri’s HIV/AIDS service providers and mental health agencies to provide services for individuals with multiple diagnoses of HIV/AIDS and mental illness and/or substance abuse.
• Training. While training is integral to almost all of these projects, seven have identified training among their most key elements. These projects include the following. The University of Mississippi Medical Center has developed a training program for physicians, dentists, and nurses in rural and urban settings throughout Mississippi. The training programs have been designed so that medical workers in rural settings who are not comfortable treating patients with AIDS will have increased knowledge and the ability to provide appropriate care. The University of Colorado Health Sciences Center has developed an eight-state program to compare different ways of providing medical information to health care providers. The Interamerican College of Physicians and Surgeons has developed a culturally appropriate training program for Hispanic physicians so that they can be trained in the management of patients with HIV disease. A key element of this program is a series of office visits to the physician by another Hispanic physician who has been trained in the management of AIDS. The University of Washington has developed a training program in neuropsychiatric illness associated with HIV disease with an emphasis on delirium, and ways of developing greater expertise among practitioners. Emory University has instituted a training program for health care providers who provide HIV-related medical services to inmates in the Georgia State prison system. Health Initiatives for Youth has developed a training center for health care, social service, and other service providers to increase their capacity to provide services in an appropriate and sensitive way to youth and adolescents. The University of Texas Health Science Center at San Antonio is using training methods to develop a comprehensive continuum of services for women with HIV and their children.

In addition to the programmatic projects, there is an Evaluation and Dissemination Center (EDC). Continuing in the second year, the EDC has provided technical assistance to HRSA/HAB's SPNS grantees in designing and implementing evaluation studies and dissemination activities for their individual projects. The EDC also assists grantees in developing and coordinating the implementation of multi-site evaluations within groups of similar projects. In addition, the EDC coordinates and facilitates the activities of the Steering Committee, such as preparing reports and presentations. The EDC also provides technical assistance to HRSA.

The EDC is a consortium headed by The Measurement Group and also includes PROTOTYPES. The Measurement Group provides overall management for the EDC and is responsible for evaluation and dissemination activities. PROTOTYPES is responsible for logistical support of the Steering Committee meetings and dissemination activities.

C. Structure and Decision-Making Processes of the Steering Committee for the Cooperative Agreement Projects