Special Projects of National Significance - Minority HIV/AIDS Fund - Goals and Objectives: The Maryland Department of Health (MDH) project aims to achieve long-term sustainability and improved outcomes in HIV care through four key areas: 1) data-driven identification of unmet healthcare and social services needs; 2) whole-person navigation services to directly link persons with HIV to needed services; 3) strengthened primary care, behavioral health, and social service partnerships; and 4) increased collaboration with healthcare coverage programs. Summary of project: Provide a brief description of the proposed project, including the proposed innovative comprehensive intervention to be implemented, specific sites where the activities will take place, and collaborating entities. Through this demonstration project, MDH will design, implement, and evaluate a multi-level, syndemic intervention to link and retain Marylanders with HIV from racial and ethnic minority groups who are out of care, and at greatest risk of being lost to care, or not achieving viral suppression in comprehensive, whole-person and integrated care. The program will adopt a tailored version of Population Health Management to prioritize enhancing the health outcomes of entire populations while also addressing the specific needs of individuals and utilize the Equitable Long-Term Recovery and Resilience model and its Seven Vital Conditions for Well-Being as a framework for implementing both direct whole-person navigation services and state-wide system strengthening activities to improve the responsiveness of Maryland healthcare and social support systems to the needs of persons with HIV convenience for program participants. Partnering with existing providers of housing, food support, medical transportation, and peer-support networks will create a holistic care ecosystem. This integrated approach addresses not just medical needs but also the social determinants of health, leading to better overall well-being. MDH program development staff will review service landscape, population health, and needs assessment data and dialogue with the community and relevant stakeholders to identify and understand health disparities, system/service gaps, and unmet needs. In response to these needs, these staff will develop partnerships, referral networks, and a comprehensive resource directory to increase access to whole-person services. Priority population(s): Initially the project will focus on individuals receiving services from the Maryland AIDS Drug Assistance Program (MADAP) who do not have evidence of HIV medical care in the past year or were not virally suppressed at their last HIV viral load test. More than 90% of the 656 MADAP participants who met these criteria in 2023 were racial/ethnic minorities (65% non-Hispanic Black, 20% Hispanic, 6% non-Hispanic other races. Because these individuals were actively enrolled in MADAP and received MADAP services during the past year, they may be more likely to be reachable by program staff and can provide insights into the unmet needs and access barriers experienced by Marylanders living with HIV. Summary of Funding: Year 1 - $500,000 Year 2 - $700,000 Year 3 - $700,000 Year 4 - $700,000