Test of an Intervention to Improve HIV Care

Inclusion Criteria:

1) Hospitalized at BTGH; 2) expected to be in the hospital for at least one more night at
the time of enrollment; 3) at least 18 years of age at enrollment; 4) able to speak
English or Spanish; 5) HIV infected, whether previously diagnosed or diagnosed this
hospital stay; 6) cognitively aware enough to provide informed consent and participate in
the study. Patients who are temporarily cognitively incapacitated (e.g., from an acute
process) will be followed and approached for enrollment if and when they are cognitively
and physically capable of participating in the study.

Exclusion Criteria:

1) Intending to use a source of HIV primary care other than TSHC after discharge from the
hospital, because TSHC-specific mentoring is not relevant to them and the data on their
appointments after discharge cannot be tracked; 2) in the opinion of the primary medical
team, likely to be discharged to an institutional setting; 3) in the opinion of the
primary medical team caring for the patient, likely to die in the hospital or be
discharged to hospice; 4) cognitive impairment that in the opinion of the primary medical
team caring for the patient is not expected to improve by discharge; 5) prisoner at
admission and expected to be discharged back to prison or jail; 6) having had an HIV
primary care visit in at least 3 of the 4 previous quarter-years AND having had at least 3
consecutive HIV VL<400 c/mL over at least 6 months, the most recent of which is within 3
months of enrollment; 7) enrolled in any other research project with prospective
follow-up; 8) already enrolled in this study at any time.

For the purposes of this study, "prisoner" will be defined in accordance with Federal
regulations, as "any individual involuntarily confined or detained in a penal
institution...[including] individuals sentenced to such an institution under a criminal or
civil statute, individuals detained in other facilities by virtue of statutes or
commitment procedures which provide alternatives to criminal prosecution or incarceration
in a penal institution, and individuals detained pending arraignment, trial, or
sentencing…Parolees who are detained in a treatment center as a condition of parole are
prisoners; however, persons living in the community and sentenced to community-supervised
monitoring, including parolees, are not prisoners." Parolees meeting the definition of
prisoner will be ineligible for the study.