Resource Library > HIV Care Continuum > Retaining in Care

Topic: Retaining in Care

Engagement in HIV/AIDS care falls along a continuum, from not being in care at all to being fully engaged, with interim points that reflect inonsistent and non-engagement in care. Varied interventions can enhance care engagement (e.g., HIV testing to help people learn their HIV status and enter care, motivational interviewing, street outreach, adherence support, case management to help clients navigate the health system, in-reach services within an HIV clinic like follow-up with patients).

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Guidelines and Manuals

  • HRSA HIV/AIDS Bureau
    April 2014

    This manual was developed to provide clinicians with ready access to practical, current, treatment information so that they may provide quality care to people living with HIV.

Webinars and Training

Tools and Job Aids

  • National Center for Innovation in HIV Care
    June 2015

    This handout from the National Center for Innovation in HIV Care includes a compilation of articles, webinars, and websites that are especially pertinent to ASOs and CBOs considering organizational restructuring or adopting service models that can improve care for clients along the HIV continuum.

  • Oregon Health Authority
    October 2012

    Series of care plan forms to assess clients in terms of intake, assessment, and care. Forms include: intake, eligibility determination, residency verification, screening for care and psychological services, client rights and responsibilities, nursing assessment, and a care plan.

  • Iowa Department of Public Health
    September 2011

    Tool for clients to use in recording weekly goals as part of their overall care plan to outline goals and objectives for HIV/AIDS care.

  • Iowa Department of Public Health
    September 2011

    Care plan agreement form between a client and case manager on the goals and objectives of care (Who, What, Where, How, When, How Often, Progress/Outcome/Date).

  • HRSA HIV/AIDS Bureau
    January 2011

    Methods that involve persons living with HIV/AIDS (PLWHA) to help link other PLWHA into primary medical care and other needed services.

  • HRSA HIV/AIDS Bureau
    October 2010

    Toolkit for implementing a comprehensive program to support HIV-positive youth transitioning from adolescent to adult HIV care. Also provides information on how to set up and supervise a program for young adult leaders on self-management and life skills.

  • Hartford Department of Health and Human Services
    February 2010

    Form for staff to assess care plan needs of clients, every 6 months, in terms of case management, home health, respite, housing, mental health, substance abuse treatment, legal, and financial assistance.

  • Seattle-King County Public Health
    January 2010

    Quarterly consumer awareness campaigns to improve the quality of care for people with HIV in Seattle-King County.

  • HRSA HIV/AIDS Bureau
    August 2009

    Building Blocks is a training compendium for agencies seeking to develop programs that utilize peers to help engage and retain other people living with HIV/AIDS in care.

  • HRSA HIV/AIDS Bureau
    January 2009
    Conjunto de herramientas para apoyar la contratación, capacitación y supervisión de pares (peers) VIH positivos, en el trabajo de involucrar y retener en la atención médica, a personas viviendo con el VIH/SIDA.
  • Matthew 25
    January 2009

    Brief list of client responsibilities used by a Ryan White clinic in explaining what is expected of them, such as active engagement in the care plan, sharing of information with staff, and appropriate conduct.

  • Matthew 25
    January 2009

    One page agreement for clients outlining their rights and responsibilities as clients of a clinic. Document discusses confidentiality, honest and open communication, managing health responsibly, and keeping the clinic informed about financial and lifestyle changes.

  • January 2009

    Series of one-page surveys to assess client understanding of each of the following: medications, health maintenance, HIV and transmission, lab tests/health problems, information.

  • El Rio Community Health Center
    January 2009

    Client-administered assessment tools to assist clinicians in working with clients on adherence to medication regimens.

  • Christiana Care Health Services
    January 2009

    Clinician assessment tool to use with clients in assessing their readiness to engage in HIV-related primary medical care and adhere to regimens.

  • HIV/AIDS Bureau
    January 2007

    Satisfaction survey for clients of Kentucky's HIV/AIDS Care Coordinator Program that seeks to facilitate the provision of care to HIV-infected individuals and their families.

  • University of Connecticut, Center for Health, Intervention, and Prevention
    January 2007

    Tools to help clinics implement HIV prevention (risk reduction) with their HIV-positive patients, using such techniques as brief motivational interviewing and a plan of action for patients. OPTIONS was field-tested by Ryan White SPNS projects.

  • HRSA HIV/AIDS Bureau
    January 2005

    Ideas for enhancing service linkages among agencies in order to improve coordination of services among key points of entry into HIV/AIDS care. Includes a process for building partnerships, overcoming barriers to agency linkages, and creating a Memorandum of Understanding (MOU) documenting agency agreement to work together.

  • HRSA HIV/AIDS Bureau
    June 2004

    Collection of tools (e.g., client interview form, outreach encounter, chart review, evaluation questions) for collecting information on contacts with clients enrolled in a SPNS supported multi site evaluation on outreach.

  • Variables used in New York City jails to assess needs of PLWHA pre-release and during transition to the community.

Reports and Best Practices


  • ACE TA Center
    July 2015

    Links to resources that were available in July of 2015 on state ADAP program websites. Where available we have provided links to the following information about the state program: Main page, eligibility information, formulary, financial assistance, and other key information.

  • U.S. Centers for Disease Control and Prevention
    March 2015

    High-impact HIV prevention interventionsbased upon scientifically proven, cost-effective, and scalable interventions directed to the most vulnerable populations in the geographic areas where HIV prevalence is highest.

  • HRSA HIV/AIDS Bureau

    Quality improvement campaign to improve patient retention in HIV/AIDS care.