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Poor medical care includes out-of-date treatment regimens and poor continuity of care after release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 priorityCurricula 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 MenPeer-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 / FamilyBooster and Project STARTAll 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 advocacyCover 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

CenterforceUCSF- Center for AIDS Prevention StudiesUniversity of Miami, Center for Family

StudiesCalifornia:

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 re-integration

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/knowledgeSpecific situational constraints Specific risks associated with incarceration

and separation from family/partnersInternal Review Board and COC

Intervention had to be modified to take these population specific factors into consideration

FriendsFriends

Family/Family/Family of ChoiceFamily of Choice

Health Health ServiceServiceDeliveryDeliveryInstitutionsInstitutions

ParoleParole

Drug Drug Recovery Recovery ServicesServices

Family’s SocialFamily’s SocialServices & PublicServices & PublicHousingHousing

Children’s Children’s HealthHealthCareCare

MesosystemsMesosystems

MicrosystemsMicrosystems

ExosystemsExosystems

SET-Re-EntrySET-Re-Entry

Soci

al

Soci

al

Serv

ices

Serv

ices

HousingHousing

HIV+ Male

Parolee

SET Re-Entry StudyParticipants 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, CaliforniaSan Quentin State Prison,San Francisco County Jail

Eligibility Criteria

18 years of age or olderBeing released to an unrestricted

environmentHIV seropositiveAble to name at least one person who

would work with him in the programBeing 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 post-release to assess longer term impact on health and behavior

Medical record reviews

Current Project Status

Pilot study began in February, 2005To test study procedures, acceptability of the

intervention10 participantsFollow-up for 4 months only

Recruitment for main study began July, 2005

Recruitment was completed in April, 2007Currently conducting follow-up surveys

Current Project Status162 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 Status0 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: 576399 (69%) with project counselor only177 (30%) with family or ecosystem

members32% Community Case Manager11% Parole Officer10% Mother7% Wife/Girlfriend7% Boyfriend33% Other (Friend, Physician, CBO staff)

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 relativeSupport personActive 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., MPHUCSF Center for AIDS Prevention Studies (CAPS)(415) 597-9168ogrinstead@psg.ucsf.edu

Barry Zack, MPHCenterforce(415) 456-9980bzack@centerforce.org