Inclusion Criteria:  PLWH and eligible for/enrolled in DC Cohort study age 16 or older speaks and reads English or Spanish at 4th grade level or above can provide informed consent; if a minor, is in charge of own HIV care plans to reside in the DC metro area for the next 12M  has at least one of the following indicators of poor retention (in order of priority):  detectable virus, not retained in care, returning to care after a gap of ≥6 months, d) no visit constancy newly diagnosed or initiating HIV care recently transferred from a different HIV care site evidence of HIV care receipt at a DC Cohort site and a non-DC Cohort site based on the DOH (Department of Health) linkage(~9%).  Exclusion Criteria:  age below 16, or if patient is 16-17; parent is in charge of HIV care unable to provide legal, independent consent to participate PLWH receiving care at two DC Cohort sites (~10%) will be excluded