ABSTRACT
The twin epidemics of HIV and incarceration impact Puerto Rico, which has limited resources to address the social and structural determinants of health in incarcerated populations. A Special Programs of National Significance grant supported a Puerto Rican community-based organization to implement the evidence-informed Transitional Care Coordination intervention among incarcerated persons living with HIV, targeting changes at the individual, organization, and systems levels. After implementation (November 2015-July 2018; n = 69), 93.1% of eligible clients were linked to community-based HIV care, 86.3% remained in care for 6 months, and 78.6% remained for 12 months. A greater proportion reported consistent HIV care, ART adherence, food security, and transportation to access care. Integrating HIV case management with housing and employment services, and developing buy-in and collaboration from partners across systems of care, including after a natural disaster, led to positive client outcomes. This intervention shows promise for adaptation to other HIV care and service delivery systems.
