| Summary: | HIV is a manageable chronic disease. However, it requires knowing one’s status, retention in care, and medication adherence for viral suppression. Disadvantaged groups of persons living with HIV/AIDS (PLWHAs) who experience incarceration and major depressive disorders, homelessness, substance use and lack of social support are overwhelmed by these burdens and do not fully engage in HIV care, without help. Four Northeast Florida entities engaged in action research to influence health equity for formerly detained PLWHAs. The City of Jacksonville, Ryan White Part-A Program, Florida Department of Health-Duval, Lutheran Social Services, and Jacksonville Sherriff’s Office convened a coalition, called CAPRICE. Activities focused on intensive medical case management, linkage to core HIV services, job placement, and up to 90-days of transition housing to support the transition from jail to community. The coalition created system level relationships, with structure and processes. Next steps should focus on how to support the infrastructure for disadvantaged groups over the long-term. Estimated sustainable cost compared reasonably with published research. The local HIV Health Services Planning Council and CAPRICE members have the task of garnering financial support for this work, which aims to plug one of the leaks in the local HIV Continuum of Care.
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