Case Study: Re-engagement in HIV Care Project
Terrence Higgins Trust, The Food Chain, 4M Mentor Mothers Network, Africa Advocacy Foundation
1. What problem are we trying to solve?
In London, a significant number of people living with HIV are disengaged from HIV care, not adhering to their medication, and at risk of severe health deterioration. Barriers such as precarious living situations, transport challenges, and limited access to support systems contribute to this disengagement. The aim is to reengage 80% of referred patients by August 2025, helping them overcome these barriers, return to care, and improve their health outcomes.
2. What did we do?
Developed Personalized Support: Delivered tailored packages including food assistance, transport support (prepaid Oyster cards), and mental health/chemsex counselling.
Adapted Communication Methods: Used WhatsApp, text messages, phone calls, discreet letters, and home visits to maintain contact.
Flexible Scheduling: Adjusted care coordinators’ hours to engage patients outside of traditional working hours.
Enhanced Collaboration: Facilitated regular patient review meetings and improved team partnerships for comprehensive care.
Addressed Structural Barriers: Created a hardship fund to assist with urgent travel costs and advocated for clinics to reimburse transport promptly.
Strengthened Referral Pathways: Invited junior doctors to QI sessions to address gaps caused by staff rotations and promoted flexibility in clinic meeting locations for privacy.
3. What outcomes have we achieved so far?
Referrals & engagement:
34 referrals received from six clinics. To date, 20 patients (59%) have successfully reengaged with HIV care. Four have requested future follow-ups, while others could not be reached or declined support.
Improved Well-being:
Food assistance via The Food Chain supported mental and physical health improvements, with one participant reporting
“I feel so much better mentally and physically. I’m now taking my medications every day and planning to visit my family.”
Support and Outreach:
7 new food support referrals this quarter (11 total).
4 new chemsex counselling referrals.
12 individuals supported through the 4M Mentor Mothers Network.
Participant Demographics:
Ethnicity: 12 Black African, 5 Black Caribbean, 7 White British, 1 White Other, 1 Unknown.
Gender: 12 male, 15 female.