Background Neighborhood Health Services Corporation (NHSC), an urban community-based not-for-profit ambulatory health centre in Plainfield, New Jersey, USA, provides services to over 350 persons living with HIV/AIDS. Presently 75% of NHSC HIV patients have history of substance abuse, 62% have mental health issues and/or depression and 30% are at risk for homelessness. For these patient populations long-term health and quality of life outcomes can not be achieved and sustained without aggressive intervention around substance use, mental health and other contributing factors.

Methods NHSC incorporates a coordinated, patient-centred approach to integrating multiple prevention services and interventions with HIV primary care and treatment in a welcoming, non-threatening environment of a patient-centred medical home. Substance abuse and mental health screenings are done by clinicians upon patient enrollment and every six months thereafter. Referrals for in-depth substance abuse and mental health assessments are generated as needed or at a minimum annually per clinical protocols. Patients in need of these services receive on-going counselling and appropriate interventions on-site. Referrals are also made to off-site facilities for crisis intervention and inpatient services. Psychosocial, financial and lifestyle assessments are conducted every six months to assess patients’ risk for homelessness, substance use and unsafe lifestyle practises.

Results Resulting from an integrated, patient-centred approach to providing HIV services NHSC demonstrated the following: 95% of HIV patients received substance abuse and mental health screening; 100% received medical case management assessments. Furthermore, 57 patients receive on-going substance abuse counselling; 36 patients receive mental health counselling; 16 persons are in shelter/transitional housing; 2 persons were hospitalised for suicide prevention.

Conclusions Integration of prevention interventions with HIV care/treatment under the umbrella of Early Intervention Services allowed to: achieve improved understanding of the reality of substance abuse/mental health; establish a seamless one-stop shop service delivery model and improve patients’ access to community prevention/treatment resources.