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Adapting a Family Counseling Intervention for HIV+ Men Leaving Jail/Prison

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Adapting a Family Counseling Intervention for HIV+ Men Leaving Jail/Prison

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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

  2. 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

  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in most US prisons • HIV testing and counseling policies in US prisons are inconsistent • Poor medical care includes out-of-date treatment regimens and poor continuity of care after release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

  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

  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

  21. SET-Re-Entry Family’s Social Services & Public Housing Drug Recovery Services Friends Family/ Family of Choice HIV+ Male Parolee Parole Children’s Health Care Housing Health Service Delivery Institutions Social Services Microsystems Mesosystems Exosystems

  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, 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…

  35. Contact Information Olga Grinstead, Ph.D., MPH UCSF Center for AIDS Prevention Studies (CAPS) (415) 597-9168 Barry Zack, MPH Centerforce (415) 456-9980