Special Projects of National Significance - Minority HIV/AIDS Fund - PROGRAM ABSTRACT Project Title: Bronx Health Outcomes Project (BHOP) Applicant Organization: Montefiore Medical Center Address: 1525 Blondell Ave. Bronx, NY, 10461 Principal Investigator: Larry Bernstein, MD. Contact: Marcy Sedlacek, PhD., Project Director Phone:718-405-8530 Email msedlace@montefiore.org Funding Requested: Year 1-$500,000; Year 2, Year 3 and Year 4- $700,000 Introduction Under the auspices of Montefiore Medical Center, the Bronx Health Outcomes Project (BHOP) is a dynamic Bronx-wide initiative that brings together major health care providers and community organizations to improve health outcomes for people living with HIV (PLWH). This project seeks to enhance BHOP's efforts by adopting a syndemic approach to HIV care, focusing on linking and retaining racial and ethnic minority groups who are out of care or at risk of being lost to care. By addressing interconnected epidemics such as HIV, mental health conditions, and social determinants of health, the project aims to improve engagement and retention in care, reduce health disparities, and enhance the quality of life for the priority populations in the Bronx. BHOP goals and objectives include: 1. Improve viral suppression rates among priority populations to an average score of 80%. 2. Enhance access to mental health and support services so that 90% of people needing these services based on BHOP ARTAS are linked to such care through BHOP BHIP. a. Achieve treat-to-target goals for 50% of clients receiving BHIP intervention arm. 3. Address food insecurity, poverty, and IPV as critical social determinants of health such that 85% of BHOP clients show improvement in their needs: a. recorded in Z-codes by BHOP staff through ARTAS and b. as reported through client surveys. 4. Reduce HIV stigma and increase engagement in care: a. as reported by clients responding to BHOP surveys and b. based on engagement with the healthcare campaign. 5. Build a sustainable, integrated care model that can be replicated in other jurisdictions. BHOP will implement a combination of evidence-based and emerging interventions to address the identified needs: 1. Adapted ARTAS Intervention: Strengths-based, culturally competent HIV care, including linkages to mental health and support services. 2. Customized Behavioral Health Integration Project (BHIP): Screening, referral, and treatment for depression, anxiety, and suicidality. 3. Healthcare Campaign: Social media and print media campaign to address HIV stigma and encourage engagement in care. BHOP is an innovative syndemic and equity demonstration project designed to address the complex health needs of key populations in the Bronx, a majority-minority jurisdiction characterized by high poverty, high crime, and limited access to healthcare. BHOP aims to improve health outcomes by addressing the intersecting social determinants of health, including HIV stigma, behavioral health, and intimate partner violence (IPV), which exacerbate the health disparities faced by the Bronx’s diverse populations. This project leverages evidence-based and emerging evidence-informed interventions using HAB’s implementation science framework to create a comprehensive, multi-level evaluation structure that targets the unique needs of the priority populations identified through our needs assessment. BHOP leverages a robust existing infrastructure composed of key clinical and support service providers, including the Family Immunology Center (FIC), Montefiore Behavioral Health Center (MBHC), and Lincoln Medical and Mental Health Center (LMMC). These institutions are part of the Bronx Family Adolescent and Children Consortium (BFACC), a well-established network funded by the Ryan White HIV/AIDS Program (RWHAP) Parts A, B, and D. BHOP aims to build on this foundation, integrating and enhancing existing services to address persistent gaps in care and support for people living with HIV.
