Most religious congregations in the USA are involved with some type of social service activity, including health activities. However, relatively few formally engage with people with HIV, and many have reported barriers to introducing HIV prevention activities. We conducted a qualitative case study of HIV involvement among 14 urban congregations in Los Angeles County in 2007. In-depth qualitative interviews of lay leaders and clergy were analyzed for themes related to HIV and other health activities, including types of health issues addressed, types of activities conducted, how activities were organized, and the relationship between HIV and other health activities. We identified three primary models representing how congregations organized HIV and other health activities: (1) embedded (n = 7), where HIV activities were contained within other health activities; (2) parallel (n = 5), where HIV and other health activities occurred side by side and were organizationally distinct; (3) overlap (n = 2), where HIV and non-HIV health efforts were conducted by distinct groups, but shared some members and organization. We discuss implications of each model for initiating and sustaining HIV activities within urban congregations over time.