The Philadelphia Linkage Program: A success story

Among the outstanding medical-case management programs at ActionAIDS is the Prison Linkage Program. This program serves individuals living with HIV while incarcerated and through release from the Philadelphia Prison System.

The Philadelphia prison population has a disproportionately high HIV-prevalence rate. At the same time, this population of individuals with HIV who are formerly incarcerated has significant barriers to health care, resulting from poverty and homelessness/transience, recidivism and parole/probation issues, drug use, active mental-health issues and other factors.

ActionAlDS originally initiated a prison program in 1991, but during the past three years we have implemented an innovative “Care Coach” intensive medical-case management approach, which uses an assessment tool — our “Acuity Vulnerability Screening” (AVS) — that we developed specifically for this program to identify clients most at risk for falling out of care.

Our results with this highly challenged population far exceed levels of general population health as set forth in the National HIV-Care Continuum. PLP establishes seamless systems to link people to care immediately after diagnosis, and supports retention in care to achieve viral suppression that can maximize the benefits of early treatment and reduce transmission risk.

The problem

As an urban area with a significant high-poverty population, Philadelphia has a high HIV-prevalence rate. In a recent study that correlated socio-economic factors and HIV prevalence in Philadelphia, the Public Health Management Corporation concluded that prevalence of HIV is likely to be highest in specific census tracts where Philadelphia residents experience low socio-economic status; high concentrations of African-American residents; high death rates from homicide, AIDS, septicemia or other illnesses; high birth risk; high neighborhood instability; and high crime rates, especially crimes related to drugs and/or sex.

The residents of these high-crime neighborhoods have a high rate of incarceration. Thus, by focusing PLP on clients who are incarcerated and preparing for release, we address the HIV epidemic with the highest-risk clients in jail and, when released, who are from the areas of the city most affected by it. The Philadelphia Prison System currently houses approximately 8,000 inmates on any given day. On a per-capita basis, Philadelphia’s rate of incarceration is disproportionately high, with Philadelphia ranking fourth among the 50 jurisdictions in the United States with the largest prison populations in 2010.

The impact of HIV in our society also involves a significant racial disparity that our program addresses. Blacks/African-Americans continue to experience the most severe burden of HIV compared with other races and ethnicities. Blacks represent approximately 12 percent of the U.S. population, but accounted for an estimated 44 percent of new HIV infections in 2010. They also accounted for 41 percent of people living with HIV infection in 2011.

Who are our PLP clients?

• African-Americans, 61 percent

• White (including Hispanic), 33 percent

• More than one race, 4 percent

• Asian, 1 percent

• No race specified, 1 percent

• Males, 64 percent

• Females, 30 percent

• Transgender females, 6 percent

• Ages 30-49, 69 percent

• Heterosexual, 80 percent

• Bisexual, 10 percent

• Gay/lesbian, 2 percent

• No sexual orientation reported, 7 percent

• Clients are universally low-income.

• About 1 percent has stable/permanent

• Forty-five percent are co-infected with Hepatitis C.

• A majority needs behavioral-health services.

Viewing our client statistics, we see that this remarkable program is reaching a population of mostly African-American males, aged 30-49, who identify as heterosexual, with injection-drug use as the primary HIV risk factor (48 percent) and heterosexual contact as a secondary factor (34 percent). To our knowledge, our program is unique in having this population focus.

PLP is also highly successful — with a rate of 85 percent — in linking clients to health care upon the most challenging transition: from the jail to the community. By ensuring this continuity of medical care, we also reduce the development of drug-resistant HIV, decrease sexual-risk behaviors and, as our clients in treatment maintain low or non-detectible viral loads, we reduce or eliminate the risk of HIV transmission to others. Indeed, this is demonstrated by the 85 percent of our Care Coach clients who have been in the PLP program for two years and who have achieved viral-load suppression.

Through this program, and many others at ActionAIDS, we are creating the first AIDS-free generation.