Relative efficacy of a multisession sexual risk-reduction intervention for young men released from prisons in 4 states

"I'm not going to lay back and watch somebody die": a qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and overdose education/naloxone distribution intervention

BACKGROUND

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects.

METHODS

Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.

RESULTS

Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).

CONCLUSIONS

By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

"I'm not going to lay back and watch somebody die": A qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and naloxone distribution/overdose education intervention

Background

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs are highly effective to prevent overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about their experiences with an OEND intervention, and about how their perceptions of their rural risk environments influenced the interventions' effects.

Methods

Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.

Results

The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUD's confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (sense of responsibility to their community) and physical/healthcare environments (high overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).

Conclusions

By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered the material and informational support that allowed participants to become a part of the healthcare environment. Findings highlight need for more outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders.

Trial registration

The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

Motivational interviewing for family planning and reducing risky sexual behavior among incarcerated men nearing release: A randomized controlled pilot study

Incarcerated men are at high risk for sexually transmitted infections (STIs) and unintended partner pregnancy postrelease. Limited research has been invested in developing and testing treatments targeting risky sexual behavior and unwanted pregnancy for this at-risk population. Motivational interviewing (MI) is a promising behavioral intervention for decreasing risky sexual behaviors. This study assessed the feasibility and acceptability of MI for family planning and risky sexual behaviors with incarcerated men nearing release. Preliminary efficacy of the MI intervention was also compared to an educational control group. Thirty-two men were assessed at baseline and randomized to one 90-min session. Assessment occurred 2 months after release. MI was feasibly administered, and participants were highly satisfied with both treatments. In addition, those who received MI reported higher rates of condom use with casual partners, higher rates of partner use of hormonal contraceptives, and slightly higher rates of sex that was protected against pregnancy. Increases are readiness to discuss family planning with sexual partners, as well as reported frequency of these discussions, and increases in family planning knowledge were also found in those randomized to MI. The findings from this study indicate the need to further assess MI with this population with a full-scale clinical trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

"I Said Maybe We Should Use a Condom, and Then that Just Went South": Exploring Condomless Sex among Formerly Incarcerated Black Men in New York City, USA

More than 600,000 incarcerated individuals are released annually in the United States; a large proportion are Black men incarcerated for drug-related offenses, including drug use and possession. Formerly incarcerated Black men report elevated rates of condomless sex and sexually transmitted infections, including human immunodeficiency virus (HIV). The purpose of this study was to explore condom usage among Black men who were formerly incarcerated for drug-related offenses and living in New York City (NYC). Using a semi-structured interview guide, in-depth interviews were conducted with 26 formerly incarcerated Black men. Interviews were audio-recorded, transcribed, and entered into NVivo, then manually coded utilizing thematic analysis methods. The following four themes were identified: partner type and length of the relationship affected condom use; diminished pleasure was a barrier for condom use; challenges with ill-fitting and poor-quality condoms; and the withdrawal method was used as an HIV prevention technique. Our findings suggest that formerly incarcerated Black men are engaging in condomless sex post-incarceration. Greater exposure to prevention messages and targeted interventions with content that includes interpersonal and condom use skill-building, methods to increase pleasurable condom use, information on HIV and STI transmission modes, and access to pre-exposure prophylaxis (PrEP) may be beneficial for this population.

CareLink-Corrections Phase 1: A Feasibility Study Inside Prisons to Improve Self-Care Upon Release

CareLink-Corrections is an evidence-informed self-care management (SCM) program designed to provide nursing and health services students an opportunity to serve a vulnerable justice-involved population while learning to provide clinical care service. Within this program, SCM of health is the clinical focus and is conceptualized as a competency where the individual acquires the knowledge, skills, and attitudes that facilitate health maintenance, health care management, and/or health promotion. Thirty undergraduate nursing students and 47 incarcerated persons participated in this first phase of the program. This article presents the first step in building the program-a feasibility study to test implementation of the program to persons in prison.

Gendered stereotypes and norms: A systematic review of interventions designed to shift attitudes and behaviour

In the face of ongoing attempts to achieve gender equality, there is increasing focus on the need to address outdated and detrimental gendered stereotypes and norms, to support societal and cultural change through individual attitudinal and behaviour change. This article systematically reviews interventions aiming to address gendered stereotypes and norms across several outcomes of gender inequality such as violence against women and sexual and reproductive health, to draw out common theory and practice and identify success factors. Three databases were searched; ProQuest Central, PsycINFO and Web of Science. Articles were included if they used established public health interventions types (direct participation programs, community mobilisation or strengthening, organisational or workforce development, communications, social marketing and social media, advocacy, legislative or policy reform) to shift attitudes and/or behaviour in relation to rigid gender stereotypes and norms. A total of 71 studies were included addressing norms and/or stereotypes across a range of intervention types and gender inequality outcomes, 55 of which reported statistically significant or mixed outcomes. The implicit theory of change in most studies was to change participants' attitudes by increasing their knowledge/awareness of gendered stereotypes or norms. Five additional strategies were identified that appear to strengthen intervention impact; peer engagement, addressing multiple levels of the ecological framework, developing agents of change, modelling/role models and co-design of interventions with participants or target populations. Consideration of cohort sex, length of intervention (multi-session vs single-session) and need for follow up data collection were all identified as factors influencing success. When it comes to engaging men and boys in particular, interventions with greater success include interactive learning, co-design and peer leadership. Several recommendations are made for program design, including that practitioners need to be cognisant of breaking down stereotypes amongst men (not just between genders) and the avoidance of reinforcing outdated stereotypes and norms inadvertently.

Incarceration, HIV Risk-Related Behaviors, and Partner Characteristics Among Heterosexual Men at Increased Risk of HIV Infection, 20 US Cities

OBJECTIVES

The effect of incarceration on HIV risk-related behaviors among at-risk heterosexual men is understudied. The objective of our study was to examine the association between incarceration and HIV risk-related behaviors among a sample of predominantly non-Hispanic black and Hispanic heterosexual men residing in urban areas in the United States with a high prevalence of AIDS.

METHODS

We analyzed data from the 2013 National HIV Behavioral Surveillance system on 5321 at-risk heterosexual men using log-linked Poisson regression models, adjusted for demographic characteristics and clustered on city.

RESULTS

Of 5321 men, 1417 (26.6%) had recently been incarcerated (in the past 12 months), 2781 (52.3%) had ever been incarcerated but not in the past 12 months, and 1123 (21.1%) had never been incarcerated. Recent incarceration was associated with multiple casual female sexual partners (adjusted prevalence ratio [aPR] = 1.23; 95% confidence interval [CI], 1.05-1.44), condomless sex with multiple female sexual partners (aPR = 1.32; 95% CI, 1.06-1.66), injection drug use (aPR = 3.75; 95% CI, 2.64-5.32), and having sexual partners who were more likely to have ever injected drugs (aPR = 1.84; 95% CI, 1.48-2.28), been incarcerated (aPR = 2.28; 95% CI, 2.01-2.59), or had a concurrent sexual partner (aPR = 1.08; 95% CI, 1.05-1.11), as compared with never-incarcerated men.

CONCLUSIONS

Incarceration history was associated with HIV risk-related behaviors among heterosexual men from urban areas in the United States. Correctional rehabilitation initiatives are needed to promote strategies that mitigate HIV risk-related behaviors and promote healthy reentry into communities among heterosexual men at high risk for HIV.

HIV, Sexually Transmitted Infection, and Substance Use Continuum of Care Interventions Among Criminal Justice-Involved Black Men Who Have Sex With Men: A Systematic Review

BACKGROUND

Because Black men who have sex with men (BMSM) experience high rates of both HIV and incarceration relative to other groups, the various stages of criminal justice involvement may serve as important intervention points for addressing HIV and related conditions in this group. Although systematic reviews of HIV interventions targeting MSM in general and BMSM in particular exist, no review has explored the range and impact of HIV, sexually transmitted infection (STI), and substance use prevention and care continuum interventions focused on criminal justice-involved (CJI) populations.

OBJECTIVES

To describe the range and impact of published HIV, STI, and related substance use interventions for US-based CJI populations and to understand their relevance for BMSM.

SEARCH METHODS

We conducted systematic searches in the following databases: PubMed, MEDLINE, Cochrane, CINAHL, and PsycINFO, covering the period preceding December 1, 2016.

SELECTION CRITERIA

We selected articles in scientific publications involving quantitative findings for studies of US-based interventions that focused on CJI individuals, with outcomes related to sexual or substance use risk behaviors, HIV, or STIs. We excluded studies if they provided no demographic information, had minimal representation of the population of interest (< 30 African American or Black male or transgender participants), had study populations limited to those aged younger than 18 years, or were limited to evaluations of preexisting programs.

DATA COLLECTION AND ANALYSIS

We abstracted data from these articles on study design; years covered; study location; participant number, demographics, and sexual orientation (if available); criminal justice setting or type; health condition; targeted outcomes; and key findings. We scored studies by using the Downs and Black quality and bias assessment. We conducted linear regression to examine changes in study quality by publication year.

MAIN RESULTS

Fifty-eight articles met inclusion criteria, including 8 (13.8%) modeling or cost-effectiveness studies and 13 (22.4%) randomized controlled trials. Just 3 studies (5.2%) focused on sexual or gender minorities, with only 1 focused on BMSM. In most studies (n = 36; 62.1%), however, more than 50% of participants were Black. The most common intervention addressed screening, including 20 empirical studies and 7 modeling studies. Education-focused interventions were also common (n = 15) and usually employed didactic rather than skill-building approaches. They were more likely to demonstrate increases in HIV testing, knowledge, and condom-use intentions than reductions in sex- and drug-risk behaviors. Screening programs consistently indicated cost-effectiveness, including with BMSM. Care continuum interventions for people living with HIV showed mixed results; just 3 involved randomized controlled trials, and these interventions did not show significant differences compared with control conditions. A minority of programs targeted non-custody-based CJI populations, despite their constituting a majority of the CJI population at any given time.

AUTHORS' CONCLUSIONS

Screening CJI populations for HIV and other STIs is effective and cost-efficient and holds promise for reducing HIV in BMSM. Education-based and care provision interventions also hold promise for addressing HIV, STIs, mental health, and substance use in CJI populations. Additional empirical and modeling studies and results specific to sexual minorities are needed; their paucity represents a disparity in how HIV is addressed. Public Health Implications. HIV and STI screening programs focused on CJI populations should be a priority for reducing HIV risk and numbers of undiagnosed infections among BMSM. Funding agencies and public health leaders should prioritize research to improve the knowledge base regarding which care continuum intervention approaches are most effective for BMSM with criminal justice involvement. Developments in modeling approaches could allow researchers to simulate the impacts and costs of criminal justice involvement-related interventions that might otherwise be cost, time, or ethically prohibitive to study empirically.

Selecting Evidence-Based HIV Prevention Behavioral Interventions for HIV-Negative Persons for National Dissemination

This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was ≤ $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Criminal justice continuum for opioid users at risk of overdose

The United States (US) is in the midst of an epidemic of opioid use; however, overdose mortality disproportionately affects certain subgroups. For example, more than half of state prisoners and approximately two-thirds of county jail detainees report issues with substance use. Overdose is one of the leading causes of mortality among individuals released from correctional settings. Even though the criminal justice (CJ) system interacts with a disproportionately high number of individuals at risk of opioid use and overdose, few CJ agencies screen for opioid use disorder (OUD). Even less provide access to medication assisted treatment (e.g. methadone, buprenorphine, and depot naltrexone), which is one of the most effective tools to combat addiction and lower overdose risk. However, there is an opportunity to implement programs across the CJ continuum in collaboration with law enforcement, courts, correctional facilities, community service providers, and probation and parole. In the current paper, we introduce the concept of a "CJ Continuum of Care for Opioid Users at Risk of Overdose", grounded by the Sequential Intercept Model. We present each step on the CJ Continuum and include a general overview and highlight opportunities for: 1) screening for OUD and overdose risk, 2) treatment and/or diversion, and 3) overdose prevention and naloxone provision.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia

OBJECTIVES

The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme.

SETTING

Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties.

RESULTS

Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected.

CONCLUSION

The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.

Evidence-based recommendations to improve reproductive healthcare for incarcerated women

Purpose The purpose of this paper is to describe standards for evidence-based reproductive healthcare for incarcerated women. Design/methodology/approach The literature on reproductive healthcare in the US criminal justice system and recommendations from professional organizations were reviewed and critical areas of concern were identified. Within these areas, studies and expert opinion were synthesized and policy recommendations were formulated through an iterative process of group discussion and document revision. This brief specifically addresses women's incarceration in the USA, but the recommendations are grounded in a human rights framework with global relevance. Findings Women who are incarcerated have health needs that are distinct from those of men, and there is a clear need for gender-responsive reproductive healthcare within the criminal justice system. This brief identifies five core domains of reproductive healthcare: routine screening, menstruation-related concerns, prenatal and postpartum care, contraception and abortion, and sexually transmitted infections. The recommendations emphasize the continuity between the criminal justice system and the community, as well as the dignity and self-determination of incarcerated women. Originality/value This brief provides a unique synthesis of the available evidence with concrete recommendations for improving the reproductive healthcare for incarcerated women.

A Review of the Effectiveness of HIV Sexual Risk Prevention Interventions in Adult Prison Inmates

This article reviews the effectiveness of HIV sexual risk prevention programs among adult prison inmates. A database search was performed to identify studies that used HIV sexual risk prevention programs with incarcerated adults. Of the 234 articles identified, 9 met the inclusion criteria. In addition, 5 articles were found containing supporting information for the 9 studies reviewed, increasing the number of articles reviewed to 14. All studies reported a significant increase in knowledge or a decrease in high-risk behaviors among the inmates at the conclusion of the interventions. Common limitations included a lack of a theoretical framework used in developing the interventions, a lack of process evaluations to measure program fidelity, and a lack of validity and reliability reporting for the study surveys. However, programs and interventions targeting HIV and sexual risk reduction appear to improve the knowledge of HIV prevention and reduce risk in the adult prison inmate population.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Effect of Patient Navigation on the Likelihood of Engagement in Clinical Care for HIV-Infected Individuals Leaving Jail

OBJECTIVES

To compare the effectiveness of patient navigation-enhanced case management in supporting engagement in HIV care upon release from jail relative to existing services.

METHODS

We randomized 270 HIV-infected individuals to receive navigation-enhanced case management for 12 months or standard case management for 90 days following release from jail between 2010 and 2013. Participants were interviewed at 2, 6, and 12 months after release. We abstracted medical data from jail and city health records.

RESULTS

Patient navigation-enhanced case management resulted in greater linkage to care within 30 days of release (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.23, 3.75) and consistent retention over 12 months (OR = 1.95; 95% CI = 1.11, 3.46). Receipt of treatment for substance use disorders in jail also resulted in early linkage (OR = 4.06; 95% CI = 1.93, 8.53) and retention (OR = 2.52; 95% CI = 1.21, 5.23). Latinos were less likely to be linked to (OR = 0.35; 95% CI = 0.14, 0.91) or retained in (OR = 0.28; 95% CI = 0.09, 0.82) HIV care.

CONCLUSIONS

Patient navigation supports maintaining engagement in care and can mitigate health disparities, and should become the standard of care for HIV-infected individuals leaving jail.

An Intervention for Reducing the Sexual Risk of Men Released From Jails

Incarceration history can affect sexual health behaviors. A randomized controlled trial of a prevention intervention tailored for post-incarcerated men was administered in a reentry setting. Men ≤45 days post release were recruited into a five-session intervention study. Participants ( N = 255) were assessed and tested for three sexually transmitted diseases (STDs) and HIV at baseline and 3 months post-intervention and followed up for 3 more months. The intervention group's STD risks knowledge ( p < .001), partner communication about condoms ( p < .001), and condom application skills ( p < .001) improved. Although fewer men tested positive for an STD at 3 months post-intervention (10% vs. 8%) and no new HIV cases were found, the finding was not significant. A tailored risk reduction intervention for men with incarceration histories can affect sexual risk behaviors.

The association of recent incarceration and health outcomes among HIV-infected adults receiving care in the United States

Purpose The purpose of this paper is to describe factors associated with incarceration as well as the association between recent incarceration and HIV-related sexual risk behaviors, access to insurance, healthcare utilization (emergency department (ED) and hospital use), antiretroviral therapy (ART) prescription, and viral suppression. Design/methodology/approach Using 2009-2010 data from a cross-sectional, nationally representative three-stage sample of HIV-infected adults receiving care in the USA, the authors assessed the demographic characteristics, healthcare utilization, and clinical outcomes of HIV-infected persons who had been recently incarcerated (detention for>24 hours in the past year) using bivariate analyses. The authors used multivariable logistic regression to examine associations of recent incarceration with insurance status as well as clinical and behavioral outcomes. Findings An estimated 22,949 (95 percent confidence interval (CI) 19,062-26,836) or 5.4 percent (CI: 4.7-6.1) of all HIV-infected persons receiving care were recently incarcerated. Factors associated with recent incarceration were age <50 years, being a smoker, having high school diploma or less, being homeless, income at or below the poverty guidelines, having a geometric mean of CD4 count <500 cells/ μL, and using drugs in the past 12 months. Results from multivariable modeling indicated that incarcerated persons were more likely to use ED services, and to have been hospitalized, and less likely to have achieved viral suppression. Originality/value Recent incarceration independently predicted worse health outcomes and greater use of emergency services among HIV-infected adults currently in HIV care. Options to improve the HIV continuum of care, including pre-enrollment for healthcare coverage and discharge planning, may lead to better health outcomes for HIV-infected inmates post-release.

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.

Drug Use and Multiple Sex Partners Among Homeless Ex-Offenders: Secondary Findings From an Experimental Study

BACKGROUND

Transitioning into society after release from incarceration presents real challenges for male offenders; in California, up to 60% return to prison within 3 years after release. The risk for ongoing drug use and having sex with multiple partners is a significant challenge for ex-offenders preparing to enter the community.

OBJECTIVES

The aims are to describe drug use and sexual behavior (sex with multiple partners) prior to incarceration and 6 and 12 months after study enrollment using data obtained as part of a randomized controlled trial.

METHODS

This is a planned secondary analysis of data obtained as part of a randomized controlled trial designed to study the effects of intensive peer coaching and nurse case management, intensive peer coaching, and brief nurse counseling on hepatitis A and B vaccination adherence compared to a usual care control treatment that also included brief peer coaching and brief nurse counseling. Self-report data from subjects enrolled at one residential drug treatment facility in Los Angeles were captured at three time points: baseline and 6- and 12-month follow-up.

RESULTS

Findings showed substantive and significant reductions in drug use and engaging in sex with multiple partners 6 months after enrollment into the study compared to the baseline data, but results did not differ by study condition. At 12-month follow-up, drug use and sex with multiple partners increased but remained less than at baseline levels.

DISCUSSION

Sustaining reductions in drug use and engaging in sex with multiple partners remains a challenge after incarceration.

Exploring HIV Risk and Ex-Offender Status Among African American Church Populations: Considerations for Faith-Based Settings

Studies with the general population indicate that involvement in the correctional system is strongly associated with the risk of contracting HIV and other sexually transmitted infections. However, limited studies have examined ex-offender status and HIV risk among African Americans-a population disproportionately impacted by incarceration and HIV-and even fewer have examined these risks among African American church-affiliated populations. This study examined ex-offender status, HIV risks, and perceptions of church involvement in HIV prevention strategies among 484 participants affiliated with African American churches. Findings indicate ex-offender participants were more likely to have been tested for HIV and believed the church should be involved in HIV prevention strategies. Future research, practice, and recommendations on the design of culturally and religiously tailored interventions for ex-offender HIV prevention, screening, and linkage to care in African American church settings are discussed.

HIV-Related Sexual Risk among African American Men Preceding Incarceration: Associations with Support from Significant Others, Family, and Friends

We evaluated the association between social support received from significant others, family, and friends and HIV-related sexual risk behaviors among African American men involved in the criminal justice system. Project DISRUPT is a cohort study among African American men released from prison in North Carolina (N = 189). During the baseline (in-prison) survey, we assessed the amount of support men perceived they had received from significant others, family, and friends. We measured associations between low support from each source (<median value) and participants' sex risk in the 6 months before incarceration. Low levels of social support from significant others, family, or friends were associated with poverty and homelessness, mental disorders, and substance use. Adjusting for age, poverty, and other sources of support, perceiving low support from significant others was strongly associated with multiple partnerships (fully adjusted odds ratio (OR) 2.64, 95% confidence interval (CI) 1.29-5.42). Low significant other support also was strongly associated with sex trade involvement when adjusting for age and poverty status (adjusted OR 3.51, 95% CI 1.25-9.85) but further adjustment for low family and friend support weakened the association (fully adjusted OR 2.81, 95% CI 0.92-8.55). Significant other support was not associated with other sex risk outcomes including concurrent partnerships, anal sex, or sex with an STI/HIV-infected partner. Low family support was associated with multiple partnerships in analyses adjusting for age and poverty (adjusted OR 1.98, 95% CI 1.05-3.76) but the association weakened and was no longer significant after adjusting for other sources of support (fully adjusted OR 1.40, 95% CI 0.65-3.00); family support was not correlated with other risk behaviors. Friend support was not significantly associated with sex risk outcomes. Indicators of overall support from any source were not associated with sex risk outcomes. Helping inmates maintain ties may improve economic security and well-being during community re-entry, while supporting and strengthening relationships with a significant other in particular may help reduce sex risk. Studies should evaluate the protective effects of distinct support sources to avoid masking effects of support and to best understand the influence of social support on health.

Comprehensive HIV Prevention for Transgender Persons

Transgender persons are at high risk for HIV infection, but prevention efforts specifically targeting these people have been minimal. Part of the challenge of HIV prevention for transgender populations is that numerous individual, interpersonal, social, and structural factors contribute to their risk. By combining HIV prevention services with complementary medical, legal, and psychosocial services, transgender persons' HIV risk behaviors, risk determinants, and overall health can be affected simultaneously. For maximum health impact, comprehensive HIV prevention for transgender persons warrants efforts targeted to various impact levels-socioeconomic factors, decision-making contexts, long-lasting protections, clinical interventions, and counseling and education. We present current HIV prevention efforts that reach transgender persons and present others for future consideration.

Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: Implications for prevention and treatment

BACKGROUND

Central Asia is afflicted with increasing HIV incidence, low antiretroviral therapy (ART) coverage and increasing AIDS mortality, driven primarily by people who inject drugs (PWID). Reliable data about HIV, other infectious diseases, and substance use disorders in prisoners in this region is lacking and could provide important insights into how to improve HIV prevention and treatment efforts in the region.

METHODS

A randomly sampled, nationwide biobehavioural health survey was conducted in 8 prisons in Kyrgyzstan among all soon-to-be-released prisoners; women were oversampled. Consented participants underwent computer-assisted, standardized behavioural health assessment surveys and testing for HIV, HCV, HBV, and syphilis. Prevalence and means were computed, and generalized linear modelling was conducted, with all analyses using weights to account for disproportionate sampling by strata.

RESULTS

Among 381 prisoners who underwent consent procedures, 368 (96.6%) were enrolled in the study. Women were significantly older than men (40.6 vs. 36.5; p=0.004). Weighted prevalence (%), with confidence interval (CI), for each infection was high: HCV (49.7%; CI: 44.8-54.6%), syphilis (19.2%; CI: 15.1-23.5%), HIV (10.3%; CI: 6.9-13.8%), and HBV (6.2%; CI: 3.6-8.9%). Among the 31 people with HIV, 46.5% were aware of being HIV-infected. Men, compared to women, were significantly more likely to have injected drugs (38.3% vs.16.0%; p=0.001). Pre-incarceration and within-prison drug injection, primarily of opioids, was 35.4% and 30.8%, respectively. Independent correlates of HIV infection included lifetime drug injection (adjusted odds ratio [AOR]=38.75; p=0.001), mean number of years injecting (AOR=0.93; p=0.018), mean number of days experiencing drug problems (AOR=1.09; p=0.025), increasing duration of imprisonment (AOR=1.08; p=0.02 for each year) and having syphilis (AOR=3.51; p=0.003), while being female (AOR=3.06; p=0.004) and being a recidivist offender (AOR=2.67; p=0.008) were independently correlated with syphilis infection.

CONCLUSION

Drug injection, syphilis co-infection, and exposure to increased risk during incarceration are likely to be important contributors to HIV transmission among prisoners in Kyrgyzstan. Compared to the community, HIV is concentrated 34-fold higher in prisoners. A high proportion of undiagnosed syphilis and HIV infections presents a significant gap in the HIV care continuum. Findings highlight the critical importance of evidence-based responses within prison, including enhanced testing for HIV and sexually transmitted infections, to stem the evolving HIV epidemic in the region.

Lessons Learned From Dissemination of Evidence-Based Interventions for HIV Prevention

In 1999, IOM issued a report that recommended that the Centers for Disease Control and Prevention should disseminate evidence-based HIV prevention interventions (EBIs) to be implemented by health departments, community-based organizations, drug treatment centers, and clinics. Based on these recommendations, the Diffusion of Effective Behavioral Interventions Project was initiated in 2000 and began disseminating interventions into public health practice. For 15 years, the Centers for Disease Control and Prevention has disseminated 29 EBIs to more than 11,300 agencies. Lessons were identified during the 15 years of implementation regarding successful methods of dissemination of EBIs. Lessons around selecting interventions for dissemination, developing a dissemination infrastructure including a resource website (https://effectiveinterventions.cdc.gov), and engagement with stakeholders are discussed. A continuous development approach ensured that intervention implementation materials, instructions, and technical assistance were all tailored to the needs of end users, focus populations, and agency capacities. Six follow-up studies demonstrated that adopters of EBIs were able to obtain comparable outcomes to those of the original efficacy research. The Diffusion of Effective Behavioral Interventions Project may offer guidance for other large, national, evidence-based public health dissemination projects.

"Inside These Fences Is Our Own Little World": Prison-Based HIV Testing and HIV-Related Stigma Among Incarcerated Men and Women

Correctional facilities offer opportunities to provide comprehensive HIV services including education, testing, treatment, and coordination of post- release care. However, these services may be undermined by unaddressed HIV stigma. As part of a prison-based HIV testing study, we interviewed 76 incarcerated men and women from the North Carolina State prison system. The sample was 72% men, median age 31.5 years (range: 19 to 60). Thematic analysis revealed high levels of HIV-related fear and stigma, homophobia, incomplete HIV transmission knowledge, beliefs that HIV is highly contagious within prisons ("HIV miasma"), and the View of HIV testing as protective. Interviewees described social distancing behaviors and coping mechanisms they perceived to be protective, including knowing their HIV status and avoiding contact with others and shared objects. Interviewees endorsed universal testing, public HIV status disclosure, and segregation of HIV-positive inmates. Intensified education and counseling efforts are needed to ameliorate entrenched HIV-transmission fears and stigmatizing beliefs.

A Review of Opportunities to Improve the Health of People Involved in the Criminal Justice System in the United States

In the past decade, many constituencies have questioned the efficacy, cost, and unintended consequences of mass incarceration in the United States. Although substantial evidence now demonstrates that US incarceration policies have had unintended adverse health consequences, we know less about the strategies and policies that can prevent or reduce these problems for justice-involved individuals and how the criminal justice system (CJS) can contribute to the Healthy People 2020 national goal of eliminating inequities in health. This review examines strategies that have been used to improve the health of people at various stages of CJS involvement, including diversion from jail and prison stays into community settings, improvements to the social and physical environments within correctional facilities, provision of health and other services to inmates, assistance for people leaving correctional facilities to make the transition back to the community, and systems coordination and integration.

Positive Transitions (POST): Evaluation of an HIV Prevention Intervention for HIV-Positive Persons Releasing from Correctional Facilities

People with HIV who are released from custody frequently do not maintain the viral suppression and other health benefits achieved while incarcerated. This study was conducted to provide preliminary evidence of efficacy of an intervention to reduce HIV risk behaviors and increase use of HIV medical services following release from custody. People with HIV were recruited from San Francisco County jails, San Quentin State Prison and the California Medical Facility (Vacaville, CA), and randomly assigned to the "standard of care" or POST intervention. POST consisted of 4 sessions pre-release and 2 sessions post-release, focusing on HIV prevention and access to care. Behavioral data were obtained for the 3 months before incarceration and 3 months after release. Although POST participants reported a statistically significant increase in receiving health care at HIV clinics (62.5-84.4 %), there were no significant differences between the POST and control participants with respect to any primary outcomes.

HIV prevention for adults with criminal justice involvement: a systematic review of HIV risk-reduction interventions in incarceration and community settings

We summarized and appraised evidence regarding HIV prevention interventions for adults with criminal justice involvement. We included randomized and quasi-randomized controlled trials that evaluated an HIV prevention intervention, enrolled participants with histories of criminal justice involvement, and reported biological or behavioral outcomes. We used Cochrane methods to screen 32,271 citations from 16 databases and gray literature. We included 37 trials enrolling n = 12,629 participants. Interventions were 27 psychosocial, 7 opioid substitution therapy, and 3 HIV-testing programs. Eleven programs significantly reduced sexual risk taking, 4 reduced injection drug risks, and 4 increased testing. Numerous interventions may reduce HIV-related risks among adults with criminal justice involvement. Future research should consider process evaluations, programs involving partners or families, and interventions integrating biomedical, psychosocial, and structural approaches.

A scoping review of risk behaviour interventions in young men

Background

Young adult males commonly engage in risky behaviours placing them at risk of acute and chronic health conditions. The purpose of this scoping review was to provide an overview of existing literature, describing the interventions targeting risk behaviours in young adult males.

Methods

A search of seven electronic databases, grey literature and relevant journals reported in English language until May 2013 was conducted. All interventions that promoted healthy behaviours or reductions in risky behaviours to treat or prevent an associated health issue(s) in young adult males (17-35 years) in upper-middle and high-income countries were included. For inclusion the appropriate age range had to be reported and the sample had to be young adult male participants only or the outcomes reported with stratification by age and/or sex to include young adult males. Risk behaviours included: physical inactivity, poor diet, alcohol use, tobacco smoking, recreational drug use, unsafe sexual behaviours, tanning/sun exposure, violence, unsafe vehicle driving, gambling and self-harm.

Results

The search strategy identified 16,739 unique citations and the full-text of 1149 studies were retrieved and screened with 100 included studies focussed on: physical inactivity (27%), alcohol use (25%), unsafe sexual behaviour (21%), poor diet (5%), unsafe vehicle driving (5%), tobacco smoking (4%), recreational drug use (2%), and tanning/sun exposure (1%) with no relevant studies targeting violence, gambling or self-harm. Also 10% of the studies targeted multiple risk behaviours. The most common study design was randomized controlled trials (62%). Face-to-face was the most common form of intervention delivery (71%) and the majority were conducted in university/college settings (46%). There were 46 studies (46%) that included young adult male participants only, the remaining studies reported outcomes stratified by age and/or sex.

Conclusion

Risk behaviours in young men have been targeted to some extent, but the amount of research varies across risk behaviours. There is a need for more targeted and tailored interventions that seek to promote healthy behaviours or decrease risky behaviours in young men.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-957) contains supplementary material, which is available to authorized users.

The case for improving the health of ex-prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill. There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings. There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.

Is there life after DEBI? Examining health behavior maintenance in the diffusion of effective behavioral interventions initiative

The evidence-based interventions that are identified, packaged, and disseminated by the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention as part of the Diffusion of Effective Behavioral Interventions (DEBI) initiative-commonly referred to the "DEBIs"-currently represent a primary source of HIV prevention interventions for community-based providers. To date, little attention has focused on whether the intended outcomes of the DEBIs, i.e., reductions in HIV-related risk behaviors, are maintained over time. This review summarized evidence for the sustainability of the effects of the DEBIs on HIV sexual risk behavior and intravenous drug use from studies of original and adapted DEBIs. Evidence of intervention decay or a lack of any intervention effect was identified in several original and adapted versions of the DEBIs included in this review. Recommendations include modifications to current criteria for inclusion in the DEBI portfolio, in addition to the development of remediation strategies to address intervention decay. Further, theoretical models that specify the processes that underlie the maintenance of health behaviors over time should be used in developing HIV prevention interventions.

Development of an intervention to increase health service utilisation in ex-prisoners

The world prison population is growing at a rate well in excess of general population growth, with more than 10 million adults currently in custody around the world and around 30 million moving through prison systems each year. There is increasing recognition of the complex and chronic health needs of incarcerated populations, but evidence-based responses to these needs remain elusive. Most prisoners return to the community after a relatively short period of time in custody, however few transitional interventions for prisoners have been subjected to rigorous evaluation. This paper details the process of developing a service brokerage intervention for ex-prisoners in Queensland, Australia, and describes the resultant intervention. The intervention could be adapted for use in other settings and is amenable to methodologically rigorous evaluation. The collaborative design and development process involved extensive consultation with ex-prisoners and key government, community and consumer stakeholders. The intervention evolved considerably during the process of consultation, as we came to better understand the needs and priorities of our target population, and of the community organisations that served them. We consider genuine consultation with consumers, in a safe and supportive environment, to be an integral part of intervention research in this area. Given the poor outcomes experienced by many people after release from prison, evidence-based interventions developed in the way described here are urgently required.

HIV prevention and education in state prison systems: an update

The prevalence rate of HIV infection in jails and prisons is approximately 5 times the rate in the U.S. general population. The authors surveyed state prison officials to assess HIV testing and HIV prevention policies--specifically voluntary testing, group HIV prevention counseling, and peer education--in the 50 states and to determine whether those policies are associated with the characteristics of the state and its prison population.

A cluster randomized trial of utilizing a local change team approach to improve the delivery of HIV services in correctional settings: study protocol

BACKGROUND

Persons held in correctional facilities are at high risk for HIV infection and their prevalence of HIV is substantially higher than in the general population. Thus, the need for proper surveillance and care of this high risk population is a paramount public health issue. This study aims to evaluate an organization-level intervention strategy for improving HIV services for persons in prison or jail.

METHODS/DESIGN

HIV Services and Treatment Implementation in Corrections (HIV-STIC) is using a cluster randomized trial design to test an organization-level intervention designed to implement improvements in preventing, detecting, and treating HIV for persons under correctional supervision. Matched pairs of prison or jail facilities were randomized using a SAS algorithm. Facility staff members in both Experimental and Control conditions involved in HIV service delivery are recruited to receive training on HIV infection, the HIV services continuum, and relevant web-based resources. Staff members in both conditions are tasked to implement improvements in HIV prevention, testing, or treatment in their facility. In the Control condition facilities, staff participants use existing techniques for implementing improvement in a selected area of HIV services. In contrast, the Experimental condition staff participants work as a Local Change Team (LCT) with external coaching and use a structured process improvement approach to improve a selected part of the HIV services continuum. The intervention period is 10 months during which data are obtained using survey instruments administered to staff members and aggregate services delivery data. The study is being implemented in 13 pairs of correctional facilities across nine states in the US. Experimental sites are hypothesized to show improvements in both staff attitudes toward HIV services and the number and quality of HIV services provided for inmates.

DISCUSSION

The current study examines a range of process and outcome data relevant to the implementation of a Change Team approach across diverse correctional settings in the United States. This initial study represents an important step toward a national best practices approach to implementing change in U.S. correctional settings and could serve as an exemplar for designing similar implementation studies.

Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey

HIV risk is disproportionately high among incarcerated individuals. Corrections agencies have been slow to implement evidence-based guidelines and interventions for HIV prevention, testing, and treatment. The emerging field of implementation science focuses on organizational interventions to facilitate adoption and implementation of evidence-based practices. A survey of correctional agency partners from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) revealed that HIV policies and practices in prevention, detection, and medical care varied widely, with some corrections agencies and facilities closely matching national guidelines and/or implementing evidence-based interventions. Others, principally attributed to limited resources, had numerous gaps in delivery of best HIV service practices. A brief overview is provided of a new CJ-DATS cooperative research protocol, informed by the survey findings, to test an organization-level intervention to reduce HIV service delivery gaps in corrections.

Cost and threshold analysis of an HIV/STI/hepatitis prevention intervention for young men leaving prison: Project START

The objectives of this study were to: (a) estimate the costs of providing a single-session HIV prevention intervention and a multi-session intervention, and (b) estimate the number of HIV transmissions that would need to be prevented for the intervention to be cost-saving or cost-effective (threshold analysis). Project START was evaluated with 522 young men aged 18-29 years released from eight prisons located in California, Mississippi, Rhode Island, and Wisconsin. Cost data were collected prospectively. Costs per participant were $689 for the single-session comparison intervention, and ranged from $1,823 to 1,836 for the Project START multi-session intervention. From the incremental threshold analysis, the multi-session intervention would be cost-effective if it prevented one HIV transmission for every 753 participants compared to the single-session intervention. Costs are comparable with other HIV prevention programs. Program managers can use these data to gauge costs of initiating these HIV prevention programs in correctional facilities.

Understanding the revolving door: individual and structural-level predictors of recidivism among individuals with HIV leaving jail

Incarceration, particularly when recurrent, can significantly compromise the health of individuals living with HIV. Despite this, the occurrence of recidivism among individuals with HIV has been little examined, particularly among those leaving jail, who may be at especially high risk for return to the criminal justice system. We evaluated individual- and structural-level predictors of recidivism and time to re-incarceration in a cohort of 798 individuals with HIV leaving jail. Nearly a third of the sample experienced at least one re-incarceration event in the 6 months following jail release. Having ever been diagnosed with a major psychiatric disorder, prior homelessness, having longer lifetime incarceration history, having been charged with a violent offense for the index incarceration and not having health insurance in the 30 days following jail release were predictive of recidivism and associated with shorter time to re-incarceration. Health interventions for individuals with HIV who are involved in the criminal justice system should also target recidivism as a predisposing factor for poor health outcomes. The factors found to be associated with recidivism in this study may be potential targets for intervention and need to be further explored. Reducing criminal justice involvement should be a key component of efforts to promote more sustainable improvements in health and well-being among individuals living with HIV.

Pilot evaluation of the Making Employment Needs [MEN] count intervention: addressing behavioral and structural HIV risks in heterosexual black men

Few community-based HIV interventions exist for Black men at heterosexual risk for HIV. None focus on structural HIV risks such as unemployment and unstable housing. This study involved a pilot evaluation of the MEN (Making Employment Needs) Count HIV intervention, a three session peer counselor-delivered program of HIV risk reduction and gender-equity counseling, and employment and housing case management. A single-arm intervention trial of MEN Count was conducted with Black men recruited from a community men's clinic and social services program. Eligible men were those who reported two or more sex partners in the past six months and current unemployment and/or recent homelessness. Most participants (68%) had a history of incarceration. Participants (N = 50) were surveyed on outcomes at baseline (Time 1), posttest (Time 2; 60-90 days after baseline), and two-month follow-up (Time 3). The majority of participants were retained in the program (86%) and the final follow-up survey (76%). McNemar tests revealed significant reductions in the past 30-day unprotected sex from Time 1 (74%) to Time 2 (47%) and to Time 3 (47%), and in homelessness from Time 1 (58%) to Time 3 (32%). Significant increases in employment from Time 1 (8%) to Time 2 (29%) and Time 3 (32%) were also seen. Participants completed a brief participant satisfaction survey at posttest. Most (n=28, 65%) rated the program as excellent, and an additional 10 (23%) rated it as good. Although there was no significant reduction in multiple sex partners, a trend was observed from Time 1 (56%) to Time 2 (44%) and Time 3 (42%). Findings suggest that the MEN Count model is a feasible and promising HIV prevention program for Black men at heterosexual risk for HIV. Larger scale implementation and more rigorous evaluation of MEN Count are needed to confirm the study findings.

HIV-risk characteristics in community corrections

OBJECTIVE

Individuals in the criminal justice system engage in behaviors that put them at high risk for HIV. This study sought to identify characteristics of individuals who are under community corrections supervision (eg, probation) and at risk for HIV.

METHODS

Approximately 25,000 individuals under community corrections supervision were assessed for HIV risk, and 5059 participants were deemed high-risk or no-risk. Of those, 1519 exhibited high sexual-risk (SR) behaviors, 203 exhibited injection drug risk (IVR), 957 exhibited both types of risk (SIVR), and 2380 exhibited no risk. Sociodemographic characteristics and drug of choice were then examined using univariate and binary logistic regression.

RESULTS

Having a history of sexual abuse, not having insurance, and selecting any drug of choice were associated with all forms of HIV risk. However, the effect sizes associated with the various drugs of choice varied significantly by group. Aside from those common risk factors, very different patterns emerged. Female gender was a risk factor for the SR group but was less likely to be associated with IVR. Younger age was associated with SR, whereas older age was associated with IVR. Black race was a risk factor for SR but had a negative association with IVR and SIVR. Living in a shelter, living with relatives/friends, and being unemployed were all risk factors for IVR but were protective factors for SR.

CONCLUSIONS

Distinct sociodemographic and substance use characteristics were associated with sexual versus injection drug use risk for individuals under community corrections supervision who were at risk for HIV. Information from this study could help identify high-risk individuals and allow tailoring of interventions.

An ecosystem-based intervention to reduce HIV transmission risk and increase medication adherence among inmates being released to the community

HIV+ inmates reentering their communities are at increased risk for poor health outcomes and for transmitting HIV. This article reports on a randomized trial comparing an ecosystem-based intervention and an individually focused intervention for reducing HIV transmission risk and improving medication adherence. Reincarceration was considered as a secondary variable. Both groups decreased sexual risk behavior over the 12-month follow-up period. Unexpectedly, the ecosystem intervention group was less likely to be taking medication or to be adherent and more likely to have been reincarcerated. Failure to demonstrate a significant advantage of the ecosystem intervention may have resulted from the difficulty of engaging family and other ecosystem members in the intervention. Implications for developing and applying interventions for this population are discussed.

"The skill is using your big head over your little head": what black heterosexual men say they know, want, and need to prevent HIV

Although the disproportionate toll of HIV/AIDS among Black heterosexuals, particularly in low-income U.S. urban areas is well documented, Black heterosexual men are rarely the explicit focus of HIV prevention messages, research, and interventions. We conducted 4 focus groups with 28 Black men, aged 19 to 51 years, who were enrolled in the workforce and fatherhood development program of a local community-based organization to examine (a) the priority and role of HIV/AIDS in their lives and (b) their HIV prevention needs. Although none articulated HIV as a top life priority, respondents nonetheless prioritized educating their children about HIV prevention and protecting their main partners from HIV if they had other sexual partners. Analyses demonstrated that participants said they wanted and needed: to learn how to talk to partners about HIV testing and use condoms when tempted not to do so, and more discussion-oriented educational opportunities to learn and exchange prevention strategies.

Burden of infectious diseases, substance use disorders, and mental illness among Ukrainian prisoners transitioning to the community

Background

The epidemics of incarceration, substance use disorders (SUDs), and infectious diseases are inextricably intertwined, especially in the Former Soviet Union (FSU). Few objective data documenting this relationship regionally are available. We therefore conducted a comprehensive, representative country-wide prison health survey in Ukraine, where one of the world’s most volatile HIV epidemics persists, in order to address HIV prevention and treatment needs.

Methods

A nation-wide, multi-site randomly sampled biobehavioral health survey was conducted in four Ukrainian regions in 13 prisons among individuals being released within six months. After consent, participants underwent standardized health assessment surveys and serological testing for HIV, viral hepatitis, and syphilis.

Results

Of the 402 participants (mean age = 31.9 years), 20.1% were female. Prevalence of HIV, HCV, HBV, and syphilis was 19.4% (95% CI = 15.5%–23.3%), 60.2% (95% CI = 55.1%–65.4%), 5.2% (95% CI = 3.3%–7.2%), and 10% (95% CI = 7.4%–13.2%), respectively, with regional differences observed; HIV prevalence in the south was 28.6%. Among the 78 HIV-infected inmates, 50.7% were unaware of their HIV status and 44 (56.4%) had CD4<350 cells/mL, of which only five (11%) antiretroviral-eligible inmates were receiving it. Nearly half of the participants (48.7%) reported pre-incarcertion drug injection, primarily of opioids, yet multiple substance use (31.6%) and alcohol use disorders (56.6%) were common and 40.3% met screening criteria for depression.

Conclusions

This is the only such representative health study of prisoners in the FSU. This study has important implications for regional prevention and treatment because, unlike elsewhere, there is no recent evidence for reduction in HIV incidence and mortality in the region. The prevalence of infectious diseases and SUDs is high among this sample of prisoners transitioning to the community. It is critical to address pre- and post-release prevention and treatment needs with the development of linkage programs for the continuity of care in the community after release.