Research has shown that two-thirds of people released from prison and living with HIV (PWH) experience interrupted care (MMWR, 2016). Effective linkage to care between corrections and community services is essential to ensure viral suppression and retention in care. ReConnect Us: A Prison Initiative is a collaboration between the South Carolina Department of Public Health (DPH), the South Carolina Department of Corrections (SCDC), and Prisma Health that supports HIV viral suppression among previously incarcerated individuals diagnosed with HIV who are re-entering the community.
Goals
- Enhance pre- and post-release planning to strengthen and coordinate medical, behavioral health, and social services for incarcerated individuals
- Identify individuals diagnosed with HIV and assist with monitoring and care management post-release
- Provide Partner Services and testing to identify partners and associates in need of HIV & STI treatment or prevention services
Target Population
Individuals who are incarcerated and diagnosed with HIV in the state of South Carolina.
Strategies
Through this cooperative effort, DPH, SCDC, and Prisma Health will share information regarding lab test results, medical appointment attendance, linkage to care, and services. This cooperative effort provides support and resources to achieve or maintain viral suppression. ReConnect Us includes activities such as:
- Enhanced pre-release planning
- Linkage to and/or re-engagement into HIV medical care
- Assistance in reaching and maintaining viral suppression
- Retention services
- Resources for partners and associates
Enhanced Pre-Release Planning
The intake process is coordinated by SCDC. Upon arrival at the intake facility, individuals are screened to ensure that emergent health needs are identified and met. All individuals are tested for HIV. Additional HIV labs are performed either with initial intake labs or after the original labs are returned. All individuals with HIV-positive labs are seen by the Infectious Disease Team (IDT) in the SCDC Internal Medicine/Specialty Clinic. If an individual arrives with HIV medication, the medication is ordered and continued by the intake provider prior to being seen by IDT. If an individual arrives with a lapse in medication, they are not restarted on medication until they have been seen by IDT. Designated staff will meet with the individual to review the purpose of the specialty clinic, discuss linkage to additional support services, the importance of antiretroviral (ART) adherence (Undetectable equals Untransmittable (U=U)), HIV medical care, and optimum overall health. Individuals are provided an overview of the ReConnect Us program during the intake process. Enhanced discharge planning is conducted in collaboration with Prisma Health Immunology to coordinate medical care and support services for individuals to be released from prison back into the community. SCDC introduces individuals to Partner Services and reviews the Disease Intervention Specialist brochure. The following documents are completed by SCDC: DpPH Referral and Follow-up Form to Disease Intervention Services, Authorization for Release of Information from SCDC to PH, and the Letter of Eligibility for ADAP application.
Linkage to and/or Re-engagement in HIV Medical Care
The PH Transitional Coordinator coordinates with providers to establish linkage to medical care and supportive services for clients post-release. The PH Transitional Coordinator meets with the client pre-release to provide HIV education, identify barriers to retention in care, complete the application for ADAP services, and schedule appointments to link clients to medical care and support services. The Transitional Coordinator works collaboratively with the SCDC Medical Discharge Planner post-release services to ensure a seamless transition back to the community.
Individuals released from a South Carolina State Prison will be enrolled in SC ADAP and will receive SC ADAP Formulary medications from an in-network pharmacy.
Individuals released from a South Carolina State Prison and relocating out of state can enroll in SC ADAP for 30 days to prevent drug therapy interruption for medications on the SC ADAP Formulary.
Retention Services & Post-Release Support
The Enhanced Discharge Planning Coordinator (EDPC) works to ensure the transition from prison back to the community occurs efficiently through ongoing communication with the client and the coordinated care team. The EDPC supports the client along the care continuum and continuously collaborates with the MCM at each receiving agency to ensure client retention in care and treatment adherence.
Resources for Partners and Associates
Partner Services assists with linking individuals and their partners to testing, treatment, medical care, STI/HIV prevention services, and other medical services to improve health outcomes. The goal is to prevent the spread of STIs and reduce the harmful effects of complications. Services are offered for the following infections: chlamydia, gonorrhea, syphilis, and HIV. DIS will attend the scheduled discharge planning clinic to meet the client(s) and provide support for prevention in the future. The DIS will interview and counsel the client, educate the client on partner services, complete a risk reduction plan, and refer high-risk negative partners to PrEP.
ReConnect Us works with HIV medical providers across South Carolina to help individuals retain care and achieve viral suppression.
For more information about ReConnect Us: A Prison Initiative please contact Monetha B. Gaskin, Continuum of Care Program Manager at (803) 898-0691 or Gaskinmb@dph.sc.gov.