HIV/AIDS Care Linkage and Retention

Across the DC, MD, and VA region, approximately 40% of people living with HIV are not accessing medical care at least twice a year (the basic HIV care guidelines established by U.S. Preventative Services Task Force).

Our linkage to and retention in care programs aim to:

  1. Link people who are not in medical care to a medical home;
  2. Increase the frequency of medical visits for all people living with HIV/AIDS to meet the recommended guidelines for HIV care; and
  3. Increase the likelihood that people living with HIV will stay in medical care for a lifetime by connecting them to resources to address barriers to utilizing care, increasing HIV literacy, and creating treatment self-efficacy and a self-value of staying in care.

Using Trained Peers to Complement Conventional Medical and Outreach Strategies

Since the beginning of the HIV epidemic, CHWs have been an essential component of the HIV care and prevention system. Beginning in 2011, we have developed and managed a number of broad-scale CHW initiatives focused on increasing HIV care utilization throughout the District of Columbia, Northern and Northwest Virginia, West Virginia and Prince George’s County, Maryland. Through these interventions, we have systematized the use of CHWs as integral members of medical and HIV care teams across the region.

CHWs have worked at their employing or host organizations and in the community to identify individuals who are HIV positive and not receiving HIV medical care in order to:

  • Build trust and inform them about living with HIV;
  • Provide personalized assistance to help them enter medical care; and
  • Support them throughout the early part of their care until they are fully involved.

Through our early intervention and retention in care work, we have had formal partnerships with 18 community and medical organizations and a cadre of 30+ HIV-specialty CHWs working across the region. Nearly 20 of those CHWs have been our employees placed at our partner sites. We have reached thousands of residents of the DC, MD, and VA region through these programs.

Our model is to partner with community-based organizations, managed care organizations, and medical sites, which include hospitals, community clinics, Federally Qualified Health Centers (FQHCs), and health departments, that are closely connected to the communities most affected by the epidemic. We work with our partner sites to recruit, train, and integrate CHWs and then support the sites and CHWs to effectively identify, link, and retain persons in care.

CHWs are expected to work closely with clinical and case management staff. This allows them to effectively identify eligible clients and to coordinate CHW support services with case managers, nurses or physicians, and other staff. Some CHWs may cover non-clinical points of entry, including testing sites and various community-based organizations.


Our support also includes providing evaluation for all of our projects. We work with contracted evaluators, often with the support of national evaluation teams, to assess the processes and outcomes for our initiatives.  We have developed internal data collection systems, policies, and procedures to support the safe collection of confidential data by CHWs in accordance with HIPAA standards. CHWs on our projects utilize mobile technology to collect data and submit data in real-time to us for processing and analysis.

Examples of Our Work in Action

Examples of our HIV/AIDS Early Intervention and Retention in Care programs can be found by clicking on the following links:

For more information about our HIV/AIDS Early Intervention and Retention Care Programs, contact us at 202.747.4120 or via email at