Nurses can play an important role in coordinating the care of individuals belonging to key affected groups and assisting them to navigate services. A holistic initial assessment is needed to identify issues that can potentially undermine an individual’s care. A multidisciplinary approach is important to support the most vulnerable to remain engaged in care.
At an individual level, assessment can include the following:
- Educational needs regarding HIV treatment or prevention
- Impact of the diagnosis or treatment on the life of the individual – including pregnancy, relationship issues
- Sustainability of current accommodation settings and safety
- Sustainability of income and access to financial assistance
- Mental health and emotional needs
- Access to tailored HIV services such as S100 providers
- Disclosure of HIV status and its impact.
At an interpersonal level it may include:
- Family and community connections
- Social isolation
- Social exclusion
- Access to peer support.
Strategies that promote engagement include:
- Non-discriminatory policies and procedures
- Explicit commitment to confidentiality and support around HIV disclosure
- Regular staff education including reflection on attitudes, consciousness-raising
- Support for assertive outreach approaches
- Nursing involvement in community development interventions and projects
- Continuity of care by skilled and trusted providers
- Integrated clinical and community-based care (such as through liaison roles, care coordination roles, partnerships with community-based AIDS organisations).
Strategies found to be helpful in the international context include:
- Strengths-based case management - clients are encouraged to identify their own abilities and skills to access resources and problem-solve. This provides strong evidence for retention in HIV care
- Peer navigation including peers as part of a health-care team
- Reducing structural- and system-level barriers
- Using community-based organisations as a setting for engaging persons with HIV Infection about the importance of regular care
- Involving patients' significant others in retention in care interventions.
Recently released guidelines suggest the following practices can improve linkage and retention in care:
- Routine viral load testing 6 months and 12 months after starting on treatment, and every 12 months thereafter, if stable on treatment
- Less frequent clinic visits for those on stable ART – every 3-6 months
- ART can be distributed by trained, supervised lay providers
- Programs should include community support interventions
- Adolescent-friendly services.