In 2023, 1,686 people were newly diagnosed with HIV in New York City, with Brooklyn reporting the highest rate and 19% concurrent AIDS diagnoses. To address these disparities, the NYU Langone Family Health Centers’ Community Medicine Program (CMP)—a collaboration with the NYC shelter system—integrated medical services directly within shelters to improve outcomes among unstably housed individuals. After piloting a part-time patient navigator to support HIV-positive patients with linkage and retention in care, the program demonstrated early success and secured a grant in December 2024 to expand into a status-neutral navigation model.

This model provides on-site, point-of-care HIV testing, same-day initiation of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP), and seamless linkage to infectious disease care, behavioral health, substance use treatment, and housing services. Patient navigators offer individualized follow-up and education, addressing social determinants of health and ensuring culturally competent, trauma-informed care.

Since launch, CMP has linked numerous individuals living with HIV to stable housing, insurance, and pharmacy support, while initiating high-risk HIV-negative individuals on PrEP. Early data indicate improvements in viral suppression and care retention among participants.

By embedding rapid HIV testing and treatment services within homeless service settings, the CMP model demonstrates an effective, scalable approach to bridging healthcare access gaps. Centralizing patient navigation within shelters builds trust and continuity, fostering long-term engagement and adherence in populations often excluded from traditional healthcare systems.