Reintegrating women leaving jail into urban communities: a description of a model program

Scoping review of interventions to link individuals to substance use services at discharge from jail

INTRODUCTION

Individuals with substance use disorders (SUD) must be linked to community-based SUD treatment and other services upon their release from jail, given their high service needs and risks for relapse, recidivism, and opioid-related overdose following release.

METHOD

This scoping review identified 14 studies (28 affiliated publications) that used experimental or quasi-experimental designs to evaluate jail re-entry interventions for individuals with SUD. The team coded intervention components, study characteristics, and study outcomes based on a service continuum for treatment linkage and retention and for post-release substance use and criminal justice outcomes.

RESULTS

This review included 4 randomized controlled trials (RCT) for linkage to treatment with medications for opioid use disorder (MOUD); 4 RCTs and 4 quasi-experimental studies for linkage to non-specific SUD treatment; and 2 RCTs for linkage to HIV + SUD services. Most studies (9/14) used case management and/or peer or patient navigation as the core intervention; 2 studies provided medical management for MOUD induction and/or facilitated referral to MOUD in the community; and 3 studies used motivational-based linkage interventions. A qualitative analysis of study outcomes found evidence to support the effectiveness of a diverse range of interventions to link individuals to community-based SUD treatment, MOUD, and other services at re-entry, but limited support for intervention effects on longer-term outcomes, including treatment retention, medication adherence, recidivism, and substance use.

CONCLUSION

Future controlled trials and implementation studies should help to unpack and examine core components of jail re-entry interventions and their successful implementation to enhance treatment retention and improve post-release outcomes.

The Transitions Clinic Network: Post Incarceration Addiction Treatment, Healthcare, and Social Support (TCN-PATHS): A hybrid type-1 effectiveness trial of enhanced primary care to improve opioid use disorder treatment outcomes following release from jail

BACKGROUND

In 2016, at least 20% of people with opioid use disorder (OUD) were involved in the criminal justice system, with the majority of individuals cycling through jails. Opioid overdose is the leading cause of death and a common cause of morbidity after release from incarceration. Medications for OUD (MOUD) are effective at reducing overdoses, but few interventions have successfully engaged and retained individuals after release from incarceration in treatment.

OBJECTIVE

To assess whether follow-up care in the Transitions Clinic Network (TCN), which provides OUD treatment and enhanced primary care for people released from incarceration, improves key measures in the opioid treatment cascade after release from jail. In TCN programs, primary care teams include a community health worker with a history of incarceration, and they attend to social needs, such as housing, food insecurity, and criminal legal system contact, along with patients' medical needs.

METHODS AND ANALYSIS

We will bring together six correctional systems and community health centers with TCN programs to conduct a hybrid type-1 effectiveness/implementation study among individuals who were released from jail on MOUD. We will randomize 800 individuals on MOUD released from seven local jails (Bridgeport, CT; Niantic, CT; Bronx, NY; Caguas, PR; Durham, NC; Minneapolis, MN; Ontario County, NY) to compare the effectiveness of a TCN intervention versus referral to standard primary care to improve measures within the opioid treatment cascade. We will also determine what social determinants of health are mediating any observed associations between assignment to the TCN program and opioid treatment cascade measures. Last, we will study the cost effectiveness of the approach, as well as individual, organizational, and policy-level barriers and facilitators to successfully transitioning individuals on MOUD from jail to the TCN.

ETHICS AND DISSEMINATION

Investigation Review Board the University of North Carolina (IRB Study # 19-1713), the Office of Human Research Protections, and the NIDA JCOIN Data Safety Monitoring Board approved the study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. We will disseminate study data through a web-based platform designed to share data with TCN PATHS participants and other TCN stakeholders. Clinical trials.gov registration: NCT04309565.

Transitioning into the Community: Perceptions of Barriers and Facilitators Experienced By Formerly Incarcerated, Homeless Women During Reentry-A Qualitative Study

Formerly incarcerated, homeless women on parole or probation experience individual-and structural-level barriers and facilitators as they prepare to transition into the community during reentry. A qualitative study was undertaken using focus group methods with formerly incarcerated, currently homeless women (N = 18, M_age = 37.67, SD 10.68, 23-53 years of age) exiting jail or prison. Major themes which emerged included the following: (1) access to resources-barriers and facilitators during community transition, (2) familial reconciliation and parenting during community transition, and (3) trauma and self-care support during community transition. These findings suggest a need to develop multi-level interventions at the individual, program and institutional/societal level with a gender-sensitive lens for women who are transitioning to community reentry. It is hoped that providing such resources will reduce the likelihood of homelessness and reincarceration.

The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review

BACKGROUND

Over seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery.

RESULTS

Peer-reviewed and gray literature (n = 82) describing the CHDS organizations' missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women.

CONCLUSIONS

We found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.

"They didn't give up on me": a women's transitions clinic from the perspective of re-entering women

BACKGROUND

Women recently released from incarceration have increased rates of co-occurring substance use, physical health, and mental health disorders. During re-entry, they face challenges navigating needed health services and social services stemming from these problems. Women's Initiative Supporting Health Transitions Clinic (WISH-TC) is a primary care program that facilitates treatment access for re-entering women. Strategies include support and navigation assistance from peer community health workers.

METHODS

Thirteen participants, of whom 11 had a substance use disorder, completed semi-structured interviews about their experiences in WISH-TC as part of a process evaluation. We conducted a qualitative framework analysis informed by self-determination theory.

RESULTS

WISH-TC supported autonomy as staff helped motivate women to work toward personal health goals. Women were empowered to have their health needs met, and consequently, prioritized attending clinic. Regarding competence, WISH-TC built upon women's existing knowledge to increase their health literacy and better understand their individual health needs. Relatedness support, both prior to re-entry and ongoing with clinic staff, was key in women's satisfaction with their care. The clinic made procedural changes in response to the interviews, including providing orientation for the patients and training the clinic in trauma-informed practices.

CONCLUSIONS

Our findings highlight the potential of a program for re-entering women, including those with substance use disorders to strengthen their abilities to navigate complex healthcare and societal systems. WISH-TC helped women feel supported, motivated, and competent to address their substance use, physical, and mental health conditions.

Comparing neighborhood and state contexts for women living with and without HIV: understanding the Southern HIV epidemic

In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n = 1,800) living with and without HIV in the Women's Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants' addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28-39% compared to 16-23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers.

Leveraging the U.S. Criminal Justice System to Access Women for HIV Interventions

The criminal justice (CJ) system can be leveraged to access women for HIV prevention and treatment programs. Research is lacking on effective implementation strategies tailored to the specific needs of CJ-involved women. We conducted a scoping review of published studies in English from the United States that described HIV interventions, involved women or girls, and used the CJ system as an access point for sampling or intervention delivery. We identified 350 studies and synthesized data from 42 unique interventions, based in closed (n = 26), community (n = 7), or multiple/other CJ settings (n = 9). A minority of reviewed programs incorporated women-specific content or conducted gender-stratified analyses. CJ systems are comprised of diverse access points, each with unique strengths and challenges for implementing HIV treatment and prevention programs for women. Further study is warranted to develop women-specific and trauma-informed content and evaluate program effectiveness.

Mental Health and Substance Abuse Service Engagement by Men and Women During Community Reentry Following Incarceration

Individuals reentering the community following incarceration are at high risk for experiencing mental health and substance use problems. This longitudinal study explores patterns and barriers for engaging treatment services during early reentry. Seventy-five men and 62 women in jail, prison, or community based correctional facilities (CBCFs) participated in pre- and post-release interviews. Findings indicate that services were engaged at a lower-than-needed rate and barriers were greater for individuals leaving jails compared to prison or CBCF. Exploratory factor analysis of the barriers instrument is presented. Implications for extending service access to this population are discussed, as are future directions for research.

Waiting to be Caught: The Devolution of Health for Women Newly Released from Jail

Traditionally understood ideas about health and criminal behaviors are integrally linked within an individual's health, as well as a community's health. In a time when women are increasingly jailed, it is important to examine the life ways of women who are newly released. This study, using participatory action research and critical hermeneutic data analysis techniques, examined women's health and social experiences following their release from jail. Findings suggest that women experienced an onward and downward momentum of health indices, or devolution, with regard to economic status, physical and mental health status, intimate and family relationships, and general social functioning. It is argued that basic public health and community nursing interventions would provide a more seamless transition from jail back into community and would positively impact the individual and community health issues that are embedded within the criminal activity.

Integrating health education and physical activity programming for cardiovascular health promotion among female inmates: A proof of concept study

Female inmate populations in the United States tend to be overweight, physically inactive, experience high stress, and have a history of nicotine and other drug dependence. Thus, they bear an elevated risk of cardiovascular (CV) disease than the general population. However, few evidence-based health interventions exist for this population. This study will test proof of concept, feasibility, and potential efficacy of a multiple health behavior change intervention that integrates CV-health promotion education delivered during a physical activity (PA) program (indoor cycling) tailored to this population. This study uses a quasi-experimental 2-group design with two measurement time-points: baseline and 8-week end of treatment. N=120 incarcerated women (18-59years of age) who are medically cleared for participation in PA will be enrolled. Indoor cycling instructors will be trained to deliver five health education topics over an 8-week period during twice-weekly cycling classes. Topics match the American Heart Association recommendations for CV health: (a) nutrition, (b) PA promotion, (c) weight management, (d) stress management, and (e) smoking cessation and relapse prevention. Modes of intervention include instructor advice, written materials and audio/video clips reviewed during class. CV-related and mental health measures will be assessed at both time-points. Results will guide a full scale efficacy study. Future research in this area has potential to impact the health of female inmates, a high-risk population. Moreover, this multiple health behavior change intervention model represents a community approach to health promotion that could generalize to other underserved populations who may benefit most from similar intervention efforts.

The development of a brief jail-based cervical health promotion intervention

The primary objective of this article was to describe the development and pilot implementation of a brief jail-based cervical health promotion intervention. The intervention was guided by a preliminary study of incarcerated women's cervical health knowledge, awareness, and health literacy, as well as a social and feminist approach to intervention development. We developed and conducted a pilot implementation of the Sexual Health Empowerment Project to increase cervical health knowledge, reduce barriers related to beliefs about cervical cancer, and improve self-efficacy and confidence in navigating health systems. This article offers a framework for how empirically and theory-based interventions are developed and tailored for a jail setting. Future work should include the evaluation of the long-term effects of such a disease-specific program on health behaviors and outcomes among high-risk and vulnerable groups of women as they leave jails and enter communities.

Highly Effective Birth Control Use Before and After Women's Incarceration

BACKGROUND

We examined factors associated with women's use of highly effective birth control before and after incarceration, since women with ongoing criminal justice involvement bear a disproportionate burden of sexual and reproductive health problems, including high rates of unintended pregnancy and inconsistent contraceptive use.

METHODS

Using a longitudinal study design, we conducted surveys with 102 women in an urban midwestern jail and then followed up with 66 of them 6 months after incarceration. We used stepwise logistic regression to assess individual, interpersonal, resource-based, organizational, and environmental factors associated with utilizing highly effective birth control.

RESULTS

Forty-two percent of women reported utilizing highly effective birth control (e.g., sterilization or other highly effective reversible methods) prior to incarceration, and 54% reported using these methods after release from jail (p<0.001). Ninety percent of women reported not wanting to get pregnant. Consistent use of birth control (p=0.001) and alcohol problems (p=0.027) were associated with utilization of highly effective birth control prior to incarceration. Previous pregnancies (p=0.012) were the only factor associated with utilization of highly effective birth control after release from jail.

CONCLUSIONS

Clinicians and public health practitioners can use findings from this study to develop clinical and intervention efforts aimed at improving unintended-pregnancy prevention among incarcerated women both during their confinement and during the tumultuous period after their release from jail.

Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study

OBJECTIVES

We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community.

METHODS

Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1270)-the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender.

RESULTS

Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression.

CONCLUSIONS

HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care

PURPOSE OF REVIEW

People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population.

RECENT FINDINGS

In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression.

SUMMARY

Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.

At a crossroads: reentry challenges and healthcare needs among homeless female ex-offenders

The exponential increase in the number of women parolees and probationers in the last decade has made women the most rapidly growing group of offenders in the United States. The purpose of this descriptive, qualitative study is to understand the unique gendered experiences of homeless female ex-offenders, in the context of healthcare needs, types of health services sought, and gaps in order to help them achieve a smooth transition post prison release. Focus group qualitative methodology was utilized to engage 14 female ex-offenders enrolled in a residential drug treatment program in Southern California. The findings suggested that for homeless female ex-offenders, there are a myriad of healthcare challenges, knowledge deficits, and barriers to moving forward in life, which necessitates strategies to prevent relapse. These findings support the development of gender-sensitive programs for preventing or reducing drug and alcohol use, recidivism, and sexually transmitted infections among this hard-to-reach population.

Frequent emergency department use among released prisoners with human immunodeficiency virus: characterization including a novel multimorbidity index

OBJECTIVES

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV).

METHODS

Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices.

RESULTS

Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values.

CONCLUSIONS

Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Public health implications for adequate transitional care for HIV-infected prisoners: five essential components

In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.

Risk factors for all-cause, overdose and early deaths after release from prison in Washington state

BACKGROUND

High mortality rates after release from prison have been well-documented, particularly from overdose. However, little is known about the risk factors for death after release from prison. Therefore, the objective of this study was to determine the demographic and incarceration-related risk factors for all-cause, overdose and early mortality after release from prison.

METHODS

We conducted a retrospective cohort study of inmates released from a state prison system from 1999 through 2003. The cohort included 30,237 who had a total of 38,809 releases from prison. Potential risk factors included gender, race/ethnicity, age, length of incarceration, and community supervision. Cox proportional hazards regression was used to determine risk factors for all-cause, overdose and early (within 30 days of release) death after release from prison.

RESULTS

Age over 50 was associated with an increased risk for all-cause mortality (hazard ratio [HR] 2.67 for each decade increase, 95% confidence interval [CI] 2.23, 3.20) but not for overdose deaths or early deaths. Latinos were at decreased risk of death compared to Whites only for all-cause mortality (HR 0.61, 95% CI 0.42, 0.87). Increasing years of incarceration were associated with a decreased risk of all-cause mortality (HR 0.95, 95% CI 0.91, 0.99) and overdose deaths (HR 0.80, 95% CI 0.68, 0.95), but not early deaths. Gender and type of release were not significantly associated with all-cause, overdose or early deaths.

CONCLUSIONS

Age, ethnicity and length of incarceration were associated with mortality after release from prison. Interventions to reduce mortality among former inmates are needed.

Education, empowerment and community based structural reinforcement: an HIV prevention response to mass incarceration and removal

In the context of US urban jails, incarceration is often seen as an opportune intervention point for prevention interventions in public health. For the detained individual, it is an opportunity to reflect on individual choices and the potential for changes in one's life course. For population focused public health professionals, jail detention facilities represent a concentration of health risks, and an opportunity to have an impact on a significant portion of those at risk for HIV and other health concerns. This paper presents an innovative education and empowerment model that bridges across jail walls, beginning on the inside, and continuing on the outside of jail where individuals continue to be challenged and supported toward positive health and social choices. The intervention also seeks to foment community activism in the communities to which jail detainees return, thus aiming to have a structural impact. This paper examines both the intervention model and the challenges of examining the effectiveness claims for the intervention at multiple levels.

Hazardously drinking women leaving jail: time to first drink

This study evaluated time to first drink in women being released from jail to determine predictors of early relapse among women with hazardous drinking and HIV risk behaviors. Between February 2004 and June 2007, 245 participants were recruited from the Rhode Island Department of Corrections. Following the baseline assessment, participants were randomized to a motivational intervention group or to a control condition. Follow-up assessments at 1, 3, and 6 months were completed for 210 participants. Alcohol use during follow-up occurred in 86.7% of participants, 42.4% initiated alcohol use on Day 1. The rate of initiation was associated with norms favorable to using alcohol (p < .01) and having a partner with an alcohol problem (hazard ratio [HR] = 1.62, p < .01). The rate of drink initiation decreased significantly (HR = 0.82, p < .05) as length of incarceration increased. The intervention was not associated with decreased drinking. Interventions to maintain abstinence need to reach women within their first days postrelease.

Community-based aftercare and return to custody in a national sample of substance-abusing women offenders

OBJECTIVES

We evaluated the effectiveness of the Community Relapse Prevention and Maintenance (CRPM) program, developed by Correctional Service Canada to better meet the needs of women offenders with drug problems.

METHODS

Using survival analysis, we investigated the association between exposure and nonexposure to CRPM and return to custody among a national sample of women offenders released from 1 of 6 federal institutions across Canada during the period May 1, 1998 to August 31, 2007.

RESULTS

After control for other risk factors, women who were not exposed to CRPM were 10 times more likely than were women exposed to CRPM to return to custody 1 year after release from prison, with more than a third returning to prison within the first 6 months.

CONCLUSIONS

Aftercare is a critical component of a woman's support system after she leaves prison. Strategies that improve access to community aftercare are imperative for improving the life chances and health of these women.

HIV in the epicenter of the epicenter: HIV and drug use among criminal justice populations in New York City, 1980-2007

During the 1990s, some of the highest rates of HIV infection in the United States were found among inmates in the New York City jail and prisons systems. This article traces the history of drug use and HIV infection among populations incarcerated in New York City jails and New York State prisons between 1980 and 2007. It describes and analyzes the policies and programs that were initiated to respond to these epidemics and assesses the lessons learned from almost three decades of experience with HIV among populations in New York's correctional facilities.

Enrollment in outpatient care among newly released prison inmates with HIV infection

OBJECTIVES

Although many prisoners infected with human immunodeficiency virus (HIV) initiate and adhere to treatment regimens while incarcerated, the benefits of in-prison therapy are frequently lost after community reentry. Little information is available on the percentage of released inmates who establish community-based HIV outpatient treatment in a timely fashion. We sought to determine the proportion of HIV-infected Texas prison inmates who enrolled in an HIV clinic within 90 days after release and to identify variables associated with timely linkage to clinical care.

METHODS

This was a retrospective cohort study of 1,750 HIV-infected inmates who were released from the Texas Department of Criminal Justice (TDCJ) and returned to Harris County between January 2004 and December 2007. We obtained demographic and clinical data from centralized databases maintained by TDCJ and the Harris County Health District, and used logistic regression analysis to identify factors associated with linkage to post-release outpatient

RESULTS

Only 20% of released inmates enrolled in an HIV clinic within 30 days of release, and only 28% did so within 90 days. Released inmates > or = 30 years of age were more likely than their younger counterparts to have enrolled in care at the 30- and 90-day time points. Inmates diagnosed with schizophrenia were more likely to have initiated care within 30 days. Inmates who received antiretroviral therapy while incarcerated and those who received enhanced discharge planning were more likely to begin care at both time points.

CONCLUSIONS

A large proportion of HIV-infected inmates fail to establish outpatient care after their release from the Texas prison system. Implementation of intensive discharge planning programs may be necessary to ensure continuity of HIV care among newly released inmates.

A critical review of HIV-related interventions for women prisoners in the United States

This article reviews the literature on HIV-related interventions for U.S. women prisoners, with a focus on identifying strategies that enabled women to practice safer sex, reduce drug use, and to avoid recidivism. A comprehensive search indicated that only nine such interventions were evaluated in professional journals between 1994 and 2009. These interventions involved behavioral programs for women at risk for HIV and discharge planning for women releases who were either infected with or at risk for HIV. Four interventions for incarcerated women achieved successful outcomes regarding self-empowerment and safer sex skills; 3 prison-release interventions resulted in less recidivism if not reduced HIV risk. Each intervention was nominally women-centered, with prison-release programs lacking protocols that were designed specifically for women. Based on evidence that women-centered interventions were desirable for this population, such interventions should be given high priority in criminal justice policy and care provision during the HIV epidemic.

A brief alcohol intervention for hazardously drinking incarcerated women

OBJECTIVE

To test the hypothesis that among hazardously drinking incarcerated women who are returning to the community, a brief alcohol intervention will result in less alcohol use at follow-up relative to standard of care.

METHODS

Eligible participants endorsed hazardous alcohol consumption-four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test. Participants were randomized to either an assessment-only condition or to two brief motivationally focused sessions, the first delivered during incarceration, the second 1 month later after community re-entry. Participants recalled drinking behaviors at 3 and 6 months after the baseline interview using a 90-day time-line follow-back method.

RESULTS

The 245 female participants averaged 34 years of age, and were 71% Caucasian. The mean percentage of alcohol use days in the 3 months prior to incarceration was 51.7% and heavy alcohol use days was 43.9%. Intervention effects on abstinent days were statistically significant at 3 months (odds ratio = 1.96, 95% confidence interval 1.17, 3.30); the percentage of days abstinent was 68% for those randomized to intervention and 57% for controls. At 6 months the effect of the intervention was attenuated and no longer statistically significant.

CONCLUSIONS

Among incarcerated women who reported hazardous drinking, a two-session brief alcohol intervention increased abstinent days at 3 months, but this effect decayed by 6 months. Study participants continued to drink heavily after return to the community. More intensive intervention pre-release and after re-entry may benefit hazardously drinking incarcerated women.

Women prisoners: health issues and nursing implications

The purpose of this article is to describe health issues of women prisoners, analyze the implications of these issues for nursing practice, and consider strategies to improve the health of this vulnerable population. The article focuses primarily on women prisoners in the United States and includes a brief contextual background to explain the rapid increase in their numbers. Although the incarceration of women is increasingly a global problem, the authors focus primarily on the situation in the United States.

A review of HIV/AIDS system-level interventions

The escalating HIV/AIDS epidemic worldwide demands that on-going prevention efforts be strengthened, disseminated, and scaled-up. System-level interventions refer to programs aiming to improve the functioning of an agency as well as the delivery of its services to the community. System-level interventions are a promising approach to HIV/AIDS prevention because they focus on (a) improving the agency's ability to adopt evidence-based HIV prevention and care programs; (b) develop and establish policies and procedures that maximize the sustainability of on-going prevention and care efforts; and (c) improve decision-making processes such as incorporating the needs of communities into their tailored services. We reviewed studies focusing on system-level interventions by searching multiple electronic abstracting indices, including PsycInfo, PubMed, and ProQuest. Twenty-three studies out of 624 peer-reviewed studies (published from January 1985 to February 2007) met study criteria. Most of the studies focused on strengthening agency infrastructure, while other studies included collaborative partnerships and technical assistance programs. Our findings suggest that system-level interventions are promising in strengthening HIV/AIDS prevention and treatment efforts. Based on our findings, we propose recommendations for future work in developing and evaluating system-level interventions.

Violence against women with HIV risk and recent criminal justice system involvement: prevalence, correlates, and recommendations for intervention

This research note examines the prevalence and correlates of intimate partner violence (IPV) and other violence (OV) among women (N = 529) at risk for HIV and with histories of criminal justice system involvement. The 3-month prevalences of IPV and OV were 31.2% and 18.7%, respectively. IPV was associated with having a current main partner, substance use, sexual risk behavior, trading sex, anxiety, depression, and lower self-esteem. OV was associated with no current employment or schooling, unstable housing, drug use, trading sex, anxiety, depression, and lower self-esteem. The high prevalence of violence demonstrates the need for intervention in this population; the correlates show that effective interventions must address the complex issues in these women's lives.

Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Highly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jail

We evaluated highly active anti-retroviral therapy (HAART) use and risk behaviors among 177 inmates who were HIV infected and were released and reincarcerated in San Francisco, Calif, jails over a 12-month period. During the month preceding reincarceration, HIV transmission risk behaviors were common among respondents, and 59% of those with a history of antiretroviral use were not taking HAART. HAART discontinuation was independently associated with homelessness, marijuana use, injection drug use, and not receiving community medical care. Postrelease interventions for inmates who are HIV infected are needed.

Neurological function and HIV risk behaviors of female prison inmates

The purpose of this study was to explain relationships between neurological dysfunction, HIV serological status, and HIV risk behaviors that have not been well understood. A secondary analysis was conducted on data from 117 female prison inmates. Another 18 female inmates from the same prison were further evaluated with more specific neurological, neuropsychological, and HIV risk behavior Risk Assessment Battery (RAB) measures. Neurological function, defined by valid, reliable quantitative measures of cognition, behavior/mood, cranial nerves, motor, reflexes, and sensation, was significantly correlated with HIV RAB scores (.743, p = .006), and RAB scale scores (.824, p = .001) in HIV-negative, but not HIV-positive, inmates. Specifically, the reflex deficits subscale correlated with RAB scores (.779, p = .003) and RAB scale scores (.682, p = .015) in the HIV-negative group. These findings combined with subjects' histories suggest cerebral dysfunction possibly contributes to HIV risk behaviors in certain high-risk female inmates predating HIV infection. These findings further suggest that HIV risk reduction should target neurologically impaired females as a high-risk group. Larger studies are needed to validate these findings.

A longitudinal, qualitative analysis of the context of substance use and sexual behavior among 18- to 29-year-old men after their release from prison

Substance use, sexual behavior, and reincarceration among 89 men from 5 state prisons across the USA, aged 18-29 years, were examined in relation to individual patterns of coping with community reintegration after their release from prison. Analyses of a series of qualitative interviews conducted over a 6-month period post-release revealed three global reintegration coping patterns: moving toward successful reintegration, resuming behavioral patterns that preceded incarceration, and reintegrating through withdrawal or isolation. Four key contextual factors that differentiated these three coping patterns were the consistency and extensiveness of social relationships, the nature of social support, and the degree of structural stability (e.g., stable employment and housing). Participants were assigned a Likert scale score (1 for poor rating to 3 for better rating) for their pattern of global reintegration and for their rating on each of the four contextual factors across the longitudinal qualitative interviews. Collectively, these five factors differentiated the prevalence and frequency of substance use, patterns of sexual behavior, and incidence of reincarceration as assessed by a quantitative survey administered 6 months post-release. Poorer ratings on all five contextual indices were related to the use of substances other than marijuana and alcohol. Men with less consistent social relationships reported more sexual partners. However, vaginal or anal sex without a condom was associated with greater social consistency and greater structural stability, possibly due to the presence of a steady main partner. Reincarceration was significantly associated with poorer global reintegration ratings, more negative social support, and less structural stability. These findings highlight the need to consider the role of social and structural support systems in HIV and sexually transmitted infection risk reduction interventions for men after their release from prison.

Treatment Needs and Completion of Community-Based Aftercare Among Substance-Abusing Women Offenders

BACKGROUND

Women offenders with substance abuse problems typically have many treatment needs on reentry to the community from prison. This paper explores the correlates of treatment needs among a sample of women offenders with substance-abuse problems (n = 1,404), and the relationship between their treatment needs and other background characteristics with completion of community-based treatment after parole.

METHODS

Treatment needs were assessed at admission into prison-based substance abuse treatment; participants were admitted into community-based treatment upon parole. Descriptive statistics and multiple regression were used to examine their treatment needs; logistic regression analysis was used to determine the factors related to completion of the aftercare program. Analysis of variance was used to examine ethnic differences in treatment needs.

RESULTS

Greater treatment needs were associated with unstable housing before incarceration, a history of sexual or physical abuse, mental health problems, alcohol or drug dependence, and first arrest at age <19; lower treatment needs were associated with having been mandated to prison-based treatment (versus volunteering). Mental health problems and earlier age at first arrest predicted treatment noncompletion. Drug dependence was associated with higher treatment needs and a greater likelihood of treatment completion, whereas African American and Hispanic ethnicity were both associated with lower treatment needs (compared with Whites) and a lower likelihood of treatment completion.

CONCLUSIONS

Interventions are needed to engage substance-abusing women offenders in community treatment after parole to address their treatment needs, improve their retention in treatment, and reduce the likelihood of recidivism.

Predictors of post-release primary care utilization among HIV-positive prison inmates: a pilot study

The primary aims of this exploratory pilot study were (1) to determine the proportion of a sample of HIV-positive inmates utilizing primary care after recent release, and (2) to identify variables associated with utilization of primary care at the time of a post-release interview. Sixty HIV-positive, male and female state prison inmates were interviewed approximately three months prior to release, and 30 were interviewed again between seven and 21 days after release. Variables associated with having utilized primary care at the time of a post-release interview (chi(2) p-values < 0.20) included: taking anti-HIV medications at the time of release, no alcohol use since release, living in the same place as before incarceration and rating of housing situation as 'comfortable' or 'very comfortable'. For exploratory purposes, these variables were entered into a logistic regression model. The model correctly classified 80% of cases overall. Future studies are required to ascertain whether these results would obtain with a statistically adequate sample size.

Community reentry: perceptions of people with substance use problems returning home from New York City jails

Each year about 100,000 people return to New York City communities from municipal jails. Although about four-fifths report drug or alcohol problems, few have received any formal drug treatment while in jail. Researchers and practitioners have identified a number of policies related to corrections, income, housing, and drug treatment that may be harmful to the successful reintegration of people leaving jail. In order to explore the challenges to successful community reentry, six focus groups and one in-depth interview were conducted with 37 men and women who had been released from jail or prison in the last 12 months. Participants were asked to describe their experiences prior to and immediately following release from jail. Findings suggest that many people leaving jail are not prepared for release and, upon release, face a myriad of obstacles to becoming healthy, productive members of their communities. We discuss the implications of these findings for programs and policies that promote community reintegration of individuals returning from correctional facilities.

Managing HIV/AIDS in correctional settings

Approximately one quarter of people living with HIV/AIDS in the United States pass through the correctional system, resulting in a burden of infection on the correctional health care system that has challenged correctional and public health officials. The HIV epidemic behind bars results from the high prevalence of HIV risk behaviors among those incarcerated: illicit drug use, untreated mental illness, prostitution, homelessness, and poverty. Challenges to HIV care in correctional settings include management of comorbid conditions, remoteness from HIV care sites, organizational constraints, and access to effective therapies. Despite these challenges, prisoners with HIV have derived considerable benefit from HIV detection and treatment. In order to achieve parity in HIV outcomes among vulnerable populations, effective prison-release programs that incorporate effective case management with effective drug treatment and adherence strategies are required to extend the benefit of highly active antiretroviral therapy as prisoners transition back to community settings.

Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Community case management for former jail inmates: its impacts on rearrest, drug use, and HIV risk

Dramatically increasing incarceration rates in the United States have led to large concentrations of formerly imprisoned people in poverty-stricken urban areas. Therefore, identifying ways to help inmates who exhibit multiple, serious problems and who are at great risk of experiencing poor postrelease outcomes is especially important to urban communities, as well as to service providers and policymakers concerned about these communities. Our research provides evidence about the effectiveness of one strategy, called Health Link, which recruited adult women and adolescent men while they were incarcerated in a New York City jail and offered case management services during the especially challenging first year after release. About 1,400 participants who enrolled during a 3-year period were randomly assigned either to a group that was eligible for intensive discharge planning services and community-based case management services or to a group eligible for less-intensive discharge planning and no community-based services. We investigated whether the availability of these services reduced rates of drug use, HIV risk, and rearrest. Using data from interviews and hair analysis to measure impacts during a 1-year follow-up period after clients' release from jail, we detected increased participation in drug treatment programs and weak evidence for reduced drug use. However, we did not observe reductions in rearrest rates or in activities with high risk of HIV infection. We conclude that a well-executed case management program can make modest differences in a few short-term outcomes of former inmates. However, the intervention did not lead to the hoped-for changes across a range of outcomes that would clearly indicate greater success in community reintegration or improved health.

High rates of incarceration as a social force associated with community rates of sexually transmitted infection

BACKGROUND

The United States has the highest rate of incarceration in the world. Some populations experience both high rates of incarceration and high rates of sexually transmitted infections (STIs).

METHODS

To estimate the strength of this correlation, we calculated age-adjusted Pearson correlation coefficients between rates of incarceration and of reportable STIs in the 100 counties of North Carolina in 1999.

RESULTS

Moderately strong correlations were found for chlamydia (r=0.577) and gonorrhea (r=0.521). The correlations between rates of incarceration and reported cases of acquired immunodeficiency syndrome and syphilis were weak (r=0.205 and 0.004, respectively).

CONCLUSIONS

Hypothetical causes of the stronger associations included incarceration increasing the number of infected prisoners or the infectiousness of released prisoners; an imbalance in the community sex ratio; and the negative influences of high rates of incarceration on social disorganization and collective efficacy. The magnitude of incarceration as a major force in American society, its association with some STIs, and our lack of empirical data on the potential causal connections argue for a new direction in STI research.