Effective Medical Linkage through Discharge Planning for the HIV Incarcerated Population: Care Coaching from Behind the Walls

According to the Center for Disease Control and Prevention, an estimated 1 in 7 persons living with HIV will pass through a correctional facility in their life time.  Inmates in jails and prisons across the United States are disproportionally affected by multiple health problems including HIV.  In Philadelphia, there is a strong correlation between incarceration, low income individuals and HIV transmission. In 1991 ActionAIDS expanded their care services into the Philadelphia Prison System and founded The Philadelphia Linkage Program to address this public health problem.   The primary goal of the Philadelphia Linkage Program has been to ensure the linkage of HIV positive inmates to medical and social services as they transition back into the community.  These services are initiated while the individual is incarcerated and continues post release encouraging the development of supportive relationships and increase engagement.

Under AIDS United’s Social Innovation Fund, the Philadelphia Linkage Program has expanded its prison programming with the development and implementation of a Care Coach Collaborative Model.  This model targets those HIV positive members of the incarcerated population identified as being most at risk for becoming lost to care and disengaging from vital care services.  Interrelated factors that increase this likelihood have been associated with, untreated mental health diagnosis, drug and alcohol dependency, and sub-standard housing and homelessness.  Our intervention integrates collaborative provider organizations designated to these specialized areas.   This presentation is intended to provide an overview of the interventions, components, and outcomes to illustrate how it can be realized within other communities.