Band 7 Outreach HIV CNS-retention and re-engagement

Job overview

As part of a multidisciplinary community and outreach team, and in liaison with acute HIV services across North West London, the HIV Re-engagement Clinical Nurse Specialist will enhance the provision of care to people living with HIV who are currently out of care.

The post holder will work within a partnership-led, community-based re-engagement model, delivering a “hospital without walls” approach. This includes working closely with peer support organisations, VCSO partners, the Find and Treat team, primary care, public health and specialist services to identify, trace, engage and re-engage individuals into HIV care.

The role will empower individuals to re-enter and remain in care, addressing clinical, psychological and social needs, and support improved health outcomes, independence and quality of life.

Main duties of the job

• In collaboration with the MDT, manage a caseload of individuals living with HIV who are out of care, including those with highly complex needs.
• Work autonomously to assess, plan, implement and evaluate care, including clinical assessment, blood testing and ART initiation/re-initiation within scope of practice.
• Deliver care in non-traditional settings, including homes, hostels and community venues, ensuring accessibility and flexibility.
• Undertake holistic assessments, including physical, psychological and social needs, addressing wider determinants of health.
• Provide specialist adherence support, including assessment of barriers and tailored interventions.
• Act as a key contact and advocate for patients, supporting navigation across health and social care systems.
• Work closely with peer navigators and VCSO partners to deliver wraparound, person-centred care.
• Participate in MDT reviews
• Provide advice on treatment, side effects and lifestyle factors impacting care.
• Liaise with acute and community services to facilitate rapid access to care and prevent hospital admissions.
• Identify safeguarding concerns and act in accordance with policy.
• Maintain accurate and timely documentation to support continuity of care and data reporting.
• Promote inter-agency collaboration and appropriate referrals to statutory and voluntary services.
• Act as an advocate for individuals experiencing stigma, discrimination or barriers to care.
• Participate in Clinical Supervision as required

Detailed job description and main responsibilities

• In collaboration with the MDT, manage a caseload of individuals living with HIV who are out of care, including those with highly complex needs.
• Work autonomously to assess, plan, implement and evaluate care, including clinical assessment, blood testing and ART initiation/re-initiation within scope of practice.
• Deliver care in non-traditional settings, including homes, hostels and community venues, ensuring accessibility and flexibility.
• Undertake holistic assessments, including physical, psychological and social needs, addressing wider determinants of health.
• Provide specialist adherence support, including assessment of barriers and tailored interventions.
• Act as a key contact and advocate for patients, supporting navigation across health and social care systems.
• Work closely with peer navigators and VCSO partners to deliver wraparound, person-centred care.
• Participate in MDT reviews to support case identification, triage and care planning.
• Provide advice on treatment, side effects and lifestyle factors impacting care.
• Liaise with acute and community services to facilitate rapid access to care and prevent hospital admissions.
• Identify safeguarding concerns and act in accordance with policy.
• Maintain accurate and timely documentation to support continuity of care and data reporting.
• Promote inter-agency collaboration and appropriate referrals to statutory and voluntary services.
• Act as an advocate for individuals experiencing stigma, discrimination or barriers to care.
• Participate in Clinical Supervision as required

The post holder will contribute to delivery of the following programme outcomes:

• Timely identification and engagement of individuals lost to care
• Increased rates of re-engagement into HIV services
• Rapid ART initiation and improved clinical outcomes (CD4/viral load)
• Increased viral suppression at 6 and 12 months
• Improved retention in care and reduced disengagement
• Reduction in health inequalities and unmet social need
• Improved patient wellbeing and experience
• High-quality data capture, reporting and contribution to evaluation
• Effective partnership working with peer and VCSO organisations
• Identify and meet the educational needs of patients, carers and professionals.
• Deliver training to primary care, community and VCSO partners to improve HIV knowledge and reduce stigma.
• Support mentorship, supervision and development of junior staff and students.
• Maintain own professional development in line with NMC requirements.
• Contribute to audit, evaluation and quality improvement initiatives related to re-engagement outcomes.
• Support implementation of evidence-based practice.
• Participate in data collection and reporting aligned to programme and commissioner requirements.
• Maintain up-to-date knowledge of HIV care, outreach models and inclusion health.
• Contribute to the development and delivery of the re-engagement programme.
• Participate in MDT meetings, governance structures and partnership forums.
• Support service improvement, innovation and pathway development.
• Contribute to activity reporting, data quality and performance monitoring.
• Assist in development of policies, procedures and patient information.
• Deputise for senior staff where appropriate.

The nature of this post is one of continual development and the duties and responsibilities outlined above may change to reflect service needs.

The post holder will be required to work flexibly across community settings and adhere to lone working and safety policies.

All duties must be carried out within Trust policies and professional scope of practice.

Applicant requirements

You must have appropriate UK professional registration.

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.