Transcript Hepatitis C in the Correctional Settings

Adapting a Family Counseling
Intervention for HIV+ Men
Leaving Jail/Prison
Research Perspective:
Olga Grinstead, Ph.D., MPH,
UCSF
Community Perspective:
Barry Zack, MPH,
Centerforce
Incarceration Epidemic in
the US
2.1 million Americans are currently incarcerated
in jails and prisons; 4.6 million more on
probation/parole
US has the highest per capita incarceration rate
in the world
65% of prisoners are people of color; 90% are
men
1/3 of African-American men 20-29 are involved
with the criminal justice system
Incarceration Epidemic
in the US
 2.1 million people are
incarcerated in the United
States today
 That’s 25% of all people
incarcerated worldwide
 California has the largest
state prison-system
(approx. 172,000
prisoners)
Prison Health is
Public Health
Low income people of color are at
disproportionate risk for incarceration
Prisoners are at disproportionate risk for
infectious diseases and other poor health
outcomes
9 out of 10 prisoners are eventually released
back to their communities
Prison programs represents an opportunity to
improve community health
Individuals with a history
of incarceration are:
8-10 times more likely to be living with HIV
5x more likely to be diagnosed with AIDS
9-10 times more likely to have Hepatitis C
4-17 times more likely to have active TB
Risk Behaviors Associated
with Incarceration
Tattoos done with re-used equipment
Needle sharing for injection drug use
Unprotected sexual intercourse
Prevention in Correctional
Settings
Condoms, needles and bleach are
contraband in most US prisons
HIV testing and counseling policies in US
prisons are inconsistent
Poor medical care includes out-of-date
treatment regimens and poor continuity of
care after release
Prevention in Correctional
Settings
Security is institution’s top priority
Curricula must meet institutional approval;
programs can be suspended or shut down
Challenge of maintaining trust of both
prisoners and correctional staff
No privacy and little if any confidentiality
for programs or health care
Community/Academic
Collaboration
Since 1992 collaborative relationship
between UCSF-CAPS and Centerforce, Inc.
Collaborative relationships with
Department of Corrections and specific
prisons and jails
Ongoing collaboration with prison peer
educators
Program of research would not be
possible without these collaborative
relationships
CAPS-Centerforce
Collaborative Projects
Prevention for Incarcerated Men
Peer-led HIV Orientation (2,295; 1997)
Peer-led Pre-Release Intervention (414; 1999)
Health Promotion for HIV+ Prisoners (147; 1999)
Project START: Young Men in Prison (522; 2006)
SET Re-Entry for HIV+ Men Leaving Prison (162;
2007)
CAPS-Centerforce
Collaborative Projects
Prevention for Women Partners
Love Your Man, Love Yourself (1995-1997)
The HOME Project (2003-2007)
Inside/Out: Real Stories of Men, Women and Life
After Incarceration (Video; 1999)
Evolution of our Research
Questions
Peer education lead to an increase in testing;
Increase in HIV+ people lead to Health
Promotion;
How do I tell my partner led to
Visitors / Partners / Family
Booster and Project START
All lead us to family/ecosystem support
community re-entry
family reunification
access to care and treatment
risk reduction
Effective Programs for
Incarcerated Community
Address institutional challenges and
barriers; know the system, provide
practical knowledge
Address structural and institutional as well
as individual-level change
Develop population-specific intervention
and educational materials
Work toward sustainability and community
integration from the beginning
Effective Programs for
Incarcerated Community
Participation open to all (combats stigma,
promotes social support and connection)
Promote self and community advocacy
Cover broad scope of topics rather than
focusing solely on stigma-laden issues
(HIV and AIDS)
Peer educators offer clear information and
population-specific materials and referrals
Effective Research and
Evaluation Design
Requires input from the target audience
and gatekeepers
Creativity is key: “gold standard” may not
be appropriate in all settings with all
populations
Definition of realistic and feasible
outcomes
Dissemination to all stakeholders who can
use the information
SET Project Development
CAPS/Centerforce collaborating since
1993 to develop and evaluate STD/HIV
programs for inmates and their families
University of Miami ongoing program of
research to explore application and
effectiveness of SET
Parallels between HIV+ women leaving
residential drug treatment and HIV+men
leaving prison led to this collaboration
SET Collaborative Partners
Centerforce
UCSF- Center for AIDS Prevention Studies
University of Miami, Center for Family Studies
California:
 Department of Corrections and Rehabilitation
 San Francisco County Jail
All collaborative partners are involved in the
development, implementation and evaluation of
the intervention
Components of Structural
Ecosystem Therapy
Joining: Forming a therapeutic alliance
Diagnosis: Assessing the functioning of the
system
Restructuring: transforming interactions
within the family or ecosystem to support
health-enhancing, prosocial behavior
Adaptation of SET
Adaptation of SET to the specific context
of prison release and community reintegration
Training from University of Miami (SET
model and clinical examples)
Transfer of knowledge from our previous
interventions with incarcerated men
Adaptation of SET
(Set Re-entry)
What is unique about prisoners/prison
interventions?
Specific language/knowledge
Specific situational constraints
Specific risks associated with incarceration and
separation from family/partners
Internal Review Board and COC
Intervention had to be modified to take these
population specific factors into consideration
SET-Re-Entry
Family’s Social
Services & Public
Housing
Drug
Friends
Recovery
Services
Parole
HIV+
Male
Parolee
Family/
Family of Choice Children’s Health
Care
Health
Service
Delivery
Institutions
Microsystems
Mesosystems
Exosystems
SET Re-Entry Study
Participants were randomized to individual vs
family counseling intervention. Each intervention
started inside with 2 sessions and continued for
16 weeks n the community
All participants received the standard of care,
the jail/prison transitional case management
program.
Recruitment Sites:
CA Medical Facility, Vacaville, California
San Quentin State Prison,
San Francisco County Jail
Eligibility Criteria
18 years of age or older
Being released to an unrestricted
environment
HIV seropositive
Able to name at least one person who
would work with him in the program
Being released within the study period
SET-R Intervention
At least 2 sessions pre-release: assessment,
joining, eco-grams, intervention planning,
contacting ecosystem members
Intervention continues 16 weeks post release to
modify family/ecosystem structures toward
supporting positive behavior change
Outcomes:
Risk behavior,
Medication adherence
Return to jail or prison
Evaluation Design
Pre-release interviewer administered
survey
Survey repeated 4 months post-release
(post-intervention)
Survey repeated at 8 and 12 months postrelease to assess longer term impact on
health and behavior
Medical record reviews
Current Project Status
Pilot study began in February, 2005
To test study procedures, acceptability of the
intervention
10 participants
Follow-up for 4 months only
Recruitment for main study began July, 2005
Recruitment was completed in April, 2007
Currently conducting follow-up surveys
Current Project Status
162 individuals were recruited from 3 sites
3 withdrew, 12 were dropped for administrative
reasons, and one died before the second survey
(To date five participants have died)
Follow-up rates are 90% at the 4 month four
month survey, 89% at the 8 month survey and
86% at the 12 month survey to date
50% of participants have completed at least one
follow up survey inside prison or jail
Study Sample
Age
Mean = 35 years
Transgender
7.4% (12)
Identify as gay or bisexual
29%
Ethnicity
25% defined themselves as Latino
Race
African American 57%
White 27%
Native American 4%
Pacific Islander 1%
Other 10%
Study Sample
Marital Status
Single 66%
Married 12%
Divorced 14%
Separated 9%
Domestic partner 6%
Study Sample
Education
Less than HS 37%
High School/GED 36%
Some College 25%
College degree 6%
Intervention Study Sample
Years Known HIV Status
0 to 2 years
7% (12)
2 to 7 years
20% (33)
7 to 10 years
25% (41)
10 to 20 years
30% (50)
Over 20 years
16% (26)
Ecosystem Engagement
(“Family arm”)
Total # of Post Release sessions: 576
399 (69%) with project counselor only
177 (30%) with family or ecosystem members
32%
11%
10%
7%
7%
33%
Community Case Manager
Parole Officer
Mother
Wife/Girlfriend
Boyfriend
Other (Friend, Physician, CBO staff)
Family and Ecosystem in SETRe-Entry: Lessons Learned
HIV+ people in prison and jail had few (if
any) identified ecosystem support
Identification of family/ecosystem
requires:
Creative probing to identify ecosystem
members
Participant’s freedom to define “family”
Not blood relative
Support person
Active engagement by counselor to identify
contact
Acknowledgements
 SET Project funded by NIMH
 Special thanks to our Project Officer, Willo Pequegnat
 University of Miami and Florida International University: Carleen
Robinson, José Szapocznik, Dan Feaster
 Centerforce: Barry Zack, Annette Lerma, Katie Kramer, David Caplan,
Maggie Dann, Isaiah Hurtado, Kelly Dalzel, Teresa Lee, Nadya Uribe
 UCSF Center for AIDS Prevention Studies (CAPS): Olga Grinstead,
Kathleen McCartney, Claudine Offer, Allison Futeral, Jackie Ramos
 All of our study participants and their families, however defined…
Contact Information
Olga Grinstead, Ph.D., MPH
UCSF Center for AIDS Prevention Studies (CAPS)
(415) 597-9168
[email protected]
Barry Zack, MPH
Centerforce
(415) 456-9980
[email protected]