The goal of this initiative is to develop systems and programs to increase retention and re-engagement in care and increase viral suppression among people living with HIV in San Francisco. Given our local HIV epidemic, we believe that the following individuals should be a focus of our efforts:
- Individuals with co-occurring conditions such as homelessness, mental health issues, and substance use that may challenge their ability to consistently engage in HIV care and treatment
- Youth, African American and Latino men and women, transgender persons, and the uninsured
- Individuals with a pattern of missed appointments or who begin to miss appointments
- Individuals who are not virally suppressed, with a priority on people with low CD4 counts and other co-morbidities
Under the leadership and coordination of a steering group, this work will be achieved by:
- Implementing standards of care for effective retention by providers (e.g., routine update of patient contact information, appointment reminder phone calls, follow-up for missed appointments, check-in calls for high-risk patients, communication with SFDPH surveillance to identify if patients have transferred care or left jurisdiction)
- Assuring that case managers are playing an active role in assuring medical appointment attendance of their clients, and assuring access by case managers to appointment databases
- Creating a comprehensive, citywide linkage program to identify patients falling out of care as early as possible and conduct early follow-up
- Developing a system for better provider-to-provider communication as patients transfer care between clinics and systems of care (public and private)
- Creating a care navigation hotline to provide assistance to out-of-care clients
- Coordinating surveillance data and medical records systems to better support providers and clinics to accurately identify and outreach to out-of-care patients
- Expanding housing, mental health, and substance abuse treatment to support linkage, retention, and re-engagement of patients
- Conducting program evaluation research to identify successful strategies for retention
Retention & Re-engagement Resources
[HIV ReConnect] HIV Care Options in SF
A list of HIV clinics and private HIV providers in SF, plus information about the insurance coverage they accept and how to get an appointment.