The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 15: Special Populations• If the person is chemically dependent, his or her first impulse may be to seekdrugs to relieve the anxiety of so much uncertainty.Clinicians should have a specific clinical pathway for persons recently released from jail or26 picasprison. The clinical pathway should involve the following immediate actions:• Assessment.Obtain a baseline assessment and lab work immediately.• Connection with social services staff.Arrange for the person to meet with a case manager or social worker duringthis visit, and establish contact with an outreach worker. Expect the person toneed to apply for a range of entitlements and services, especially emergencyhousing.• Reconnection with family.Identify at least one family member and begin the process of reconnection.• Continued personal contact.Make a plan for how to maintain contact. Do not expect the person to return intwo weeks for a follow-up visit; agree to have a next-day conversation.Linking Recently Released People with Community Care: ModelsThe U.S. Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB) SpecialProjects of National Significance is collaborating with the Centers for Disease Control andPrevention on an initiative to develop models to enhance prevention and care services for incarceratedpeople at risk for HIV or living with HIV. 12 Two key components of the model programsthat link inmates to community services are discharge planning while the inmate is still inprison or jail, and case management either inside the institution or outside in the community.For HIV-positive prisoners in the San Francisco County Jails, for example, The Homebase Projectarranges to have a case manager meet individuals at the gate when they are released and providesthem with up to three months’ housing in a single-room occupancy hotel, while linkingthem with social and medical services in the community. This immediate assistance is an excellentexample of an intervention for the clinical pathway described above. While incarceratedindividuals in the early stages of HIV disease may benefit from such interventions, persons withadvanced HIV disease are in even more critical need of the continuity of care that such interventionsafford. Unfortunately, these models are not the norm at correctional facilities in the U.S.326U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau