Nurses and midwives play important roles in providing and coordinating the care of individuals belonging to key populations and assisting them to navigate services. A holistic initial assessment can identify issues that affect an individual’s care. A multidisciplinary approach is important to support the most vulnerable to remain engaged in care. 

At an individual level, assessment includes the following: 

• Educational needs regarding HIV treatment or prevention 
• Impact of the diagnosis or treatment on the life of the individual – including pregnancy, relationship issues 
• Sustainability of current accommodation settings and safety 
• Sustainability of income and access to financial assistance 
• Mental health and emotional needs 
• Access to tailored HIV services such as medical and nurse practitioners who are qualified to prescribe antiretroviral therapies and to treat PLHIV (in Australia, known as S100 prescribers) 
• Disclosure of HIV status and its impact. 

At an interpersonal level, assessment includes identifying: 

• Family and community connections 
• Social isolation or social exclusion 
• Access to peer support. 

Strategies and systems that promote engagement include: 

• No cost comprehensive and multidisciplinary services (64). 
• Non-discriminatory policies and procedures 
• Explicit commitment to confidentiality and support around HIV disclosure 
• Regular staff education including reflection on attitudes, and consciousness-raising. 
• Support for assertive outreach approaches. 
• Professional (nursing and midwifery) involvement in community development interventions and projects 
• Continuity of care by skilled and trusted providers (65). 
• Integrated clinical and community-based care (such as through liaison and care coordination roles, partnerships with community-based AIDS organisations). 

Strategies found to be helpful in the international context include: 

• Strengths-based case management – clients are encouraged to identify their own abilities and skills to access resources and problem-solve.  This provides strong evidence for retention in HIV care (66). 
• Peer navigation – including peers as part of a healthcare team (64).  This includes the use of First Nations liaison workers (68, 69). 
• Reducing structural- and system-level barriers (64). 
• Using community-based organisations as a setting for engaging persons with HIV  
• Involving ‘significant others’ in retention in HIV care interventions 
• ‘Differentiated service delivery’ – fewer clinic visits, ‘one-stop-shop’ clinics and community dispensing of antiretrovirals (70). 

International research and guidelines suggest the following practices can improve linkage and retention in care: 

• Routine viral load testing 6 months and 12 months after starting on treatment, and every 12 months thereafter, if stable on treatment (71) 
• Less frequent clinic visits for those on stable ART – for example, every 3-6 months or even yearly. 
• ART can be distributed by trained, supervised lay providers. 
• Programs should include community support interventions and intensive outreach (71). 
• Adolescent-friendly services (73, 74).