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Description:The Quality Improvement (QI) initiative at Adult Special Care Clinics (ASCC) aimed to improve linkage to and retention in HIV care, and viral suppression in postpartum WWH. The intervention used (1) HIV care coordination that involved ongoing communication between ASCC staff and perinatal HIV program staff regarding pregnant women who will transition to postpartum care at ASCC. During the pregnancy, ASCC staff made face-to-face contact or phone contact to provide information about postpartum care counseling, information on HIV care and services available post-delivery, and linkage services to outpatient HIV care after delivery. Special attention is given to ensure there is no lapse in combined antiretroviral therapy (cART) due to the transition from pregnancy Medicaid to AIDS Drug Assistance Program (ADAP), assessment of mental health of mother, facilitation of transportation and scheduling of follow-up visits for outpatient HIV care; (2) intense monitoring by information tracking of referred pregnant WWH on date of diagnosis, estimated delivery date, and any known barriers to care; (3) pamphlets that addressed the unique needs and concerns of pregnant and postpartum WWH and ASCC HIV postpartum care and treatment services; and (4) case management which includes face-to face meetings and telephone calls to facilitate communication, build trust, address barriers to engagement and retention in care, and provide ancillary services as needed. ASCC staff develops an individualized care plan in coordination with each woman to address social determinants of health factors (e.g., housing, food, medication, transportation). Proactive referrals are given as needed to address barriers to retention in HIV care.
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