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Incarceration Epidemic in the US. 2.1 million Americans are currently incarcerated in jails and prisons; 4.6 million more on probation/paroleUS has the highest per capita incarceration rate in the world 65% of prisoners are people of color; 90% are men1/3 of African-American men 20-29 are involved with the criminal justice system.
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1. 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
3. 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)
4. 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
5. 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
6. Risk Behaviors Associated with Incarceration Tattoos done with re-used equipment
Needle sharing for injection drug use
Unprotected sexual intercourse
7. 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Poor medical care includes out-of-date treatment regimens and poor continuity of care after release
8. 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
9. 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
10. 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)
11. 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)
12. 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
13. 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 These suggestions and lessons learned could apply to conducting intervention research with any number of disenfranchised communities
Many of the programs described here are ongoing or the earlier program has been incorporated into the newer oneThese suggestions and lessons learned could apply to conducting intervention research with any number of disenfranchised communities
Many of the programs described here are ongoing or the earlier program has been incorporated into the newer one
14. 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
These suggestions and lessons learned could apply to conducting intervention research with any number of disenfranchised communitiesThese suggestions and lessons learned could apply to conducting intervention research with any number of disenfranchised communities
15. 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
16. 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
17. 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
18. 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
19. Adaptation of SET Adaptation of SET to the specific context of prison release and community re-integration
Training from University of Miami (SET model and clinical examples)
Transfer of knowledge from our previous interventions with incarcerated men
20. 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
22. 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
23. 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
24. 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
25. Evaluation Design Pre-release interviewer administered survey
Survey repeated 4 months post-release (post-intervention)
Survey repeated at 8 and 12 months post-release to assess longer term impact on health and behavior
Medical record reviews
26. 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
27. 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
28. 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%
29. Study Sample Marital Status Single 66%
Married 12%
Divorced 14%
Separated 9%
Domestic partner 6%
30. Study Sample Education Less than HS 37%
High School/GED 36%
Some College 25%
College degree 6%
31. 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)
32. Ecosystem Engagement (�Family arm�) Total # of Post Release sessions: 576
399 (69%) with project counselor only
177 (30%) with family or ecosystem members
32% Community Case Manager
11% Parole Officer
10% Mother
7% Wife/Girlfriend
7% Boyfriend
33% Other (Friend, Physician, CBO staff)
33. Family and Ecosystem in SET- Re-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
34. Acknowledgements SET Project funded by NIMH
Special thanks to our Project Officer, Willo Pequegnat
University of Miami and Florida International University: Carleen Robinson, Jos� 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�
35. Contact Information Olga Grinstead, Ph.D., MPH
UCSF Center for AIDS Prevention Studies (CAPS)
(415) 597-9168
ogrinstead@psg.ucsf.edu
Barry Zack, MPH
Centerforce
(415) 456-9980
bzack@centerforce.org