Ask AI
Back Back
Reconnecting People to HIV Care
Reconnecting People to HIV Care

Released: September 19, 2025

JaToya McCrae
JaToya McCrae, AAS, CCHW
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Addressing social determinants of health is essential to ensuring long-term retention in HIV care.
  • Healthcare teams can improve retention in care by conducting detailed client assessments, creating personalized care plans, and using coordinated care approaches.
  • Community partnerships expand access to culturally sensitive resources, while incentives reinforce engagement in care.

Many people living with HIV may find themselves disconnected from or lost to care at some point after their diagnosis. The disconnection may stem from challenges related to social determinants of health, such as lack of access to health services, unemployment or low/no income, food insecurity, housing instability, HIV stigma, and lack of sufficient support networks. These factors create barriers that prevent continuous engagement in care.

To address these challenges, healthcare teams must implement targeted strategies that go beyond medical support to ensure continuous engagement in HIV care. Outreach services, detailed client assessments and personalized care plans, coordinated services, community partnerships, and incentives can assist in breaking barriers to engagement in HIV care. 

Outreach Services for Reengagement in Care
Outreach services for reengaging and retaining clients in HIV treatment include phone calls, text messages, and messaging through the patient portal. This provides regular communication to remind clients of appointments, referrals, and other necessary healthcare services.

Clients who are hard to reach may need more intensive outreach, such as mailed letters and home visits to reengage them in HIV care. Mailed letters and home visits also can help to locate clients who were lost to care and assist the care team in identifying if the address on file is up-to-date.

Detailed Client Assessments and Individualized Care
Detailed client assessments and individualized care plans can identify which social determinants of health are barriers to care and provide an understanding of the client’s current circumstances.

Assessments should include the client’s housing status to identify if the client has stable housing, is experiencing homelessness, or is staying with family or friends.

The assessment should also include the client’s transportation needs. Does this client have personal transportation or use public transit? Does the client have disabilities and require specialized transportation assistance?

The assessment should also factor in the client’s income to determine their financial stability. Can they afford transportation, medication, or copays? Another factor is food security. Does the client receive government assistance or SNAP benefits to afford healthy foods? Are there healthy foods available where the client lives or nearby? Finally, does the client have a trusted support system?

The information from these assessments can then be used to establish healthcare goals and to develop care plans with the client. Each client has unique circumstances, so understanding their current needs allows the care team to access resources they may need.

For example, if the client works hours that conflict with clinic or healthcare professional’s availability, the care team may be able to provide transportation assistance to the client or offer telehealth appointments as an option. In all, detailed client assessments help with tailoring care plans to support each client’s needs and retention in care.

Care Coordination
Care coordination also reduces barriers to care. Scheduling same-day services at 1 location minimizes the need for clients to travel to different locations. This can be especially helpful if transportation is a barrier for the client. Having the client meet with their HIV provider, receive lab services, and meet with a mental health provider or case manager the same day can increase the probability of services being accessed. Warm hand-offs to service providers for behavioral health, dental, or other specialized services also helps ensure clients access those services. This eliminates barriers for clients who may be unable to do so on their own. 

Partnership With Community Organizations
Collaborating and building partnerships with community organizations expands access to needed resources for clients. For example, the HIV care team may not be able to assist the client with all their needs, but having access to organizations in the community that provide those services can break barriers to care.

In particular, people living with HIV have different cultures and backgrounds or may speak different languages so being able to provide access to resources that are culturally sensitive is important as well. People living with HIV may need access to behavioral health services for mental health and substance abuse issues, food pantries for food insecurity, or housing assistance for homelessness or intimate partner violence.

Access to peer support and connection with others living with HIV are also important for bolstering mental health. Peer support assists with social isolation that may stem from HIV stigma and provides empowerment for clients. Networking and building partnerships with local community organizations can increase access to resources for clients. The care team could also create a local resource guide for clients to refer to for their needs as well.

Incentivizing Retention in Care
HIV care teams and providers can also offer incentives for clients to increase retention in HIV care. Incentives such as transportation vouchers, gift cards, patient appreciation days, and celebrating milestones with and for clients can encourage them to be proactive about their HIV care.

Finding ways to implement continuous engagement with clients extends beyond scheduling appointments and obtaining labs. Creating ways to celebrate clients also encourages, supports, and provides trust that leads to breaking barriers to engagement in HIV care.

Ultimately, breaking barriers to engagement in HIV care is about making each individual feel seen and understood. To this end, HIV care teams can implement the strategies discussed here to create supportive environments that empower and encourage clients to stay connected in HIV care.  

Your Thoughts
How would you go about implementing any of these strategies in your practice? Leave a comment below to let us know!

Continue