forging a future:
the hiv-positive ex-offender

“They told me in prison in 1998. I did not get counseling or talk to anybody. I swallowed it. When I was in my room I tried to hang myself because I thought that I was a disease. I didn’t think I had anything to live for. Project Bridge helped me. Even when I was living on the street in the bushes, they would come find me. They gave me a chance after everyone else gave up.”

These words are Lydia Camacho’s story of how she found out she was HIV positive and what happened because she had no supports to help her through her situation. Camacho has lived in Providence, Rhode Island, for most of her 52 years. She has spent 25 years of her life either on the street or incarcerated. One of her 10 grandchildren is pregnant and will soon make her a great-grandmother. On the day of the interview, she also had three keychains from Alcoholics Anonymous vouching that she has been clean for 60 days. She is out of jail and off the streets. She is healthy. In her own words, she is a survivor. And she has Miriam Hospital’s Project Bridge, a community reentry program for HIV-positive ex-offenders, to thank.

Although Lydia’s story is unique, her circumstances are not. Twenty percent of people living with AIDS and 13 to 19 percent of people living with HIV in the general population have been incarcerated at some point in time.3 In 2004, the rate of confirmed AIDS cases among U.S. State and Federal prisoners was more than three times higher than in the total population.4

Of the estimated 35,000 to 47,000 HIV-positive people living in correctional facilities, one-third are released back into the community each year.5 Successful reentry into the community and engagement into health care is far from a sure thing. But reentry programs like Project Bridge can make all the difference.

What Issues Are in Play?

The same issues that make people like Lydia vulnerable to incarceration are also associated with high HIV infection rates. Problems include the following psychosocial and socioeconomic factors:

• Homelessness6
• Lack of insurance coverage7
• Low education level8
• Mental illness9
• Poverty10
• Racial or ethnic minority group11
• Substance abuse.12

“We use the term dually diagnosed,” remarks Sam Rivera of Fortune Society, a New York City organization staffed primarily by former prisoners and dedicated to improving prison conditions and the success of prisoner reentry.

“People come out trying to find employment and housing. They are dealing with the stigma around being a former prisoner,” Rivera explains. “And 70 percent of our clients are dealing with histories of substance abuse. Add HIV to the mix and you are dealing with another level entirely.”

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Rivera is one of many former prisoners who found hope at Fortune Society, and today he is the senior director of health and transitional services there. He describes the work of his program—which offers services as diverse as health care and housing support—as ultimately that of creating a safe and supportive environment for returning prisoners.

Upon release, inmates often return to the same resource-poor, underserved communities where they lived before incarceration. The effect is to aggravate disparities already present in this population, and it is one reason that recidivism rates are so high. An estimated 46.9 percent of State prisoners are reconvicted of a felony or serious misdemeanor within 3 years of their release.13,14

“People coming out of prison are scared—believe me,” says Rivera. “They don’t know what’s going to happen to them, and before they leave incarceration for home, the message they often get from fellow inmates and the community is, ‘You’re coming back.’”

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Keeping Problems at Bay

Reentry programs help HIV-positive ex-offenders build alternatives—and show them that although hope may be hard to come by, it is not impossible to find.

“Our thing is to break the cycle,” says Ronnie Snyder, an HIV-positive ex-offender. Snyder is director of the Re-adjustment and Re-entry (RARE) Program at the Center for Health Justice in Los Angeles, California, where he says the recidivism rate is around 84 percent. RARE and programs like it give ex-offenders access to resources for overcoming disparities and leading healthy, stable lives.

Typical components of such programs include building a relationship with the prisoner prior to release through HIV education and prevention classes and, sometimes, one-on-one HIV counseling and discharge planning. After release, the programs provide services or referrals for many of the following needs: housing; comprehensive health care that includes specialty care for diagnoses such as hepatitis C, substance abuse, and mental health disorders; employment and life skills training; and, in some cases, legal and parole support.

Reentry programs do not have the luxury of dealing with these issues in sequence. “Programs that are not designed with a prison focus—addressing issues like parole, the stigma of incarceration—just don’t cut it,” says Rivera. Moreover, programs must consistently follow through with clients to gain trust and develop a relationship that is strong enough to keep the ex-offender in care.

Establishing a Continuum of Health Care

Many inmates’ first adult encounter with the health care system occurs during incarceration, and many more struggle to find and access health care upon release.15,16 Reentry programs often help people cement a relationship with a health care provider prior to release. For example, Project Bridge, which begins working with clients 6 months in advance of their release, is affiliated with Providence’s Miriam Hospital, the provider of HIV care during and following incarceration. Thus, patients become comfortable with their doctors before reentering the community. This approach eases transition for clients—and for the physician, who becomes familiar with clients’ medical histories and care needs before they enter the unpredictable world on the outside.

“We have some women who get reincarcerated. We don’t reject them. We reopen their case and we accept them with open arms. We say, ‘Let’s do this again. Where did we go wrong, and let’s try to figure it out.’”

Once released, Project Bridge implements an 18-month intervention that focuses on retaining the client in health care and linking him or her with other services needed to build a life outside incarceration. To help clients navigate the choppy waters of the health care and social services system, Project Bridge uses a cognitive behavior model, in which a caseworker and an outreach worker demonstrate the behavior needed to successfully seek those services. “Then, little by little, we start giving the client more control to do it themselves,” says Leah Holmes, director of Project Bridge. “And at the end, they are doing it all on their own.”

This approach pays off. According to Holmes, “100 percent of people leaving the program have been in care for the last 6 months; 85 percent are still in care 6 months later.”

Being Patient, Not Punitive

The 18-month Project Bridge intervention reflects what many providers say: Patience is essential. “Far too many programs,” says Holmes, “try to give [clients] a few weeks or a few months of intervention. It just isn’t enough.”

“People don’t get into the situation of being HIV-positive and being incarcerated overnight,” she notes. “Most of our clients [at Project Bridge] have been incarcerated over four times. Their average age is 43. Most of them have been using illicit drugs for 20 years or more. Anything that has taken that long to develop will take a relatively long time before it improves.”

Snyder agrees that sometimes slow and steady really does win the race. He remarks that, in the RARE Program, “until [clients] are ready to make a change, we are there. There was one guy that we worked with in and out [of prison], but the sixth time he was in he told us, ‘I need to change. I want to do something else. I’m tired of this.’ He’s actually been out for 2 1/2 years now and has a full-time job that he enjoys.”

Housing Works, in Brooklyn, New York, provides access to essential services such as health care and housing for people living with HIV/AIDS (PLWHA), including those who are homeless. Among the organization’s 12 core programs is the Brooklyn Women’s Transitional Housing Program, which links female HIV-positive ex-offenders with services such as housing, mental health and substance abuse services, job training, and harm reduction counseling.

Julie Peña heads this program. “We have some women who get reincarcerated,” she says. “We don’t reject them. We reopen their case and we accept them with open arms. We say, ‘Let’s do this again. Where did we go wrong, and let’s try to figure it out.’”

Offering a Place to Live and Make a Living

A home and a job are top concerns of people leaving incarceration, yet they can be the hardest to come by.

Lydia Camacho says that her small one-bedroom apartment—housing arranged by Project Bridge—was the main thing that kept her on the path to recovery and out of prison. “It’s just a small corner,” she says with a shrug, “but it’s my home. It’s somewhere to put my keys. That’s what I needed for my life to be complete. I’m not ready to be on the street anymore. I can’t afford to fall down again.”

Housing is a top issue for almost all HIV-positive people. Providers deal with this issue in many different ways—often, only as budgets and availability allow. Although Project Bridge and the RARE Program do not offer on-site housing, they do have relationships with landlords and management companies to provide safe and affordable housing for their clients.

Housing Works and Fortune Society, however, do offer on-site housing to a limited degree. Housing Works’ Brooklyn Women’s Transitional Housing Program is able to house 20 women in program-leased apartments. Fortune Society operates a facility called the Fortune Academy (pictured in the box on p. 7), which provides 62 beds in single- and shared-occupancy units.

To facilitate off-site housing arrangements, Fortune Society may take care of apartment repairs as an incentive for landlords to accept their clients as residents, and they may also provide move-in and utilities fees and security deposits. In 2005, 83 clients received housing through Fortune Society programs.17

Along with housing, perhaps the biggest stressor for some of the PLWHA coming out of corrections facilities today is not living with HIV; it’s making a living. The stigma of incarceration, coupled with low education levels (less than 50 percent of prisoners have a high school diploma), exacerbates the barriers to employment that underserved PLWHA face.18

“We urge people to begin working on their employment prospects while in prison,” says Rivera. “Your job in prison can vary, but no matter what it is, we teach our clients that instead of hiding that they were incarcerated, that experience should go on their resumes.”

“A lot of our clients have never even had a checking account,” says Snyder, whose program offers a budgeting class, mock job interviewing, resume help, and other courses for developing life skills. Fortune Society’s career development unit offers similar services, where in 2006, 430 clients completed career development workshops and more than half were successfully placed in jobs.19

Some programs hire their own clients. Peña, Rivera, and Snyder are all clients turned employees. Peña’s organization, Housing Works, trains and employs clients at its thrift shop, bookstore, and catering service. The employment of ex-offenders sets a powerful example for people who are awaiting release. “Every time we get the opportunity to bring on someone who’s been out of prison a while, who’s been successful and doing well in the community, we do it,” says Rivera.

Reflecting Unique Needs

The diverse needs of subpopulations of HIV-positive inmates must be taken into account when designing reentry programs. Consider, for example, the unique needs of women.

A gender-sensitive approach can have a significant positive impact on how successfully female inmates are able to make the postincarceration transition. Female offenders seem to have a higher prevalence of psychosocial needs than male offenders (particularly as related to their familial and romantic relationships) and greater deficits in academic and vocational skills.20 Snyder observes, for example, that among his RARE Program clients, “women sometimes need a little more empowering when it comes to encouraging them to practice safe sex, because it can be taboo for a woman to tell her husband or boyfriend to use a condom. So we try to help empower them so that they can start making the right decisions once they are on the outside.”

Peña brings her personal experience to her work with HIV-positive women. “I’m a product of the criminal justice system,” she says, “and I understand that many women go through the revolving door of incarcerations because they don’t have the skills to be productive in society. Some are victims of domestic violence, or they’ve been traumatized, or they’ve been raped, or they’ve been homeless. Some have had their children taken away.”

Among the problems that disproportionately affect female inmates and the corrections population at large are mental illness and substance abuse. Drug convictions that carry mandatory sentencing have skyrocketed, and since 1980, incarceration rates for women have risen at nearly double the rate for men.21,22 In Federal prison, approximately 60 percent of women, compared with 40 percent of men, have been convicted of drug-related offenses.23,24

In addition, the rate of mental illness is more than three times higher among inmates than in the general population.25 Mental illness often goes untreated because its symptoms can be difficult to recognize.

“Sometimes it’s hard for clients to accept that they have mental health issues,” says Peña. “And as long as you don’t accept it, it doesn’t get treated—and women go back out and put themselves at risk for getting arrested again. We try to help them understand that there is nothing wrong with suffering from depression. There are medications, and you might not even need that. Sometimes someone to talk to is all it takes.”

“We try to help women,” she continues, “by having a psychologist on site; having our women attend our adult day treatment program; or engaging them in peer education or another structured, positive experience.”

Building a Relationship With the Corrections System

Without a collaborative relationship with the corrections system, little opportunity exists to establish client relationships and plan for prisoner reentry into the community. But building a relationship with a corrections system can present a formidable challenge. It first requires recognizing the disconnect between the objectives of correctional facilities (safety and conformity) and community-based reentry programs (primary and secondary HIV prevention and information and psychosocial support services).

The most significant advice to offer someone going to work within a prison for the first time is, “Remember you are only a visitor here,” says Rivera. “You have to remember the etiquette of being in someone else’s space and remember your role,” he adds.

The providers highlighted in this article offer the following tips as a guide to building a relationship with corrections systems.

1. Get proper clearance.
Find out what is needed to receive clearance for providing services and who is allowed—and not allowed—to come into the facility. (Ex-offenders may be banned, for example.) Approval for an event may require 30 to 90 days and 5 to 15 signatures, according to Rivera. “Understanding the meaning of time in relationship to any idea and its delivery is crucial,” he adds.

2. Respect confidentiality.
Confidentiality within the corrections facility and the provider setting is vital. Provider staff must know the rules regulating with whom and under what circumstances client information can be shared. Confidentiality issues should be addressed proactively with each client.

3. Present solutions, not problems.
Corrections facilities have their own set of priorities, goals, and challenges. It is important not to slow or inhibit the functioning of the institution but, instead, to help it function at its best. If an unmet need or a problem among the clients being served is identified, “you can’t go at [the corrections personnel] with the attitude that they are doing it wrong,” says Snyder. “You’ve got to go at it with the attitude that things aren’t running the best, but here’s how we can make things run better for everyone—including the institution.”

4. Let your work be your biggest advocate.
Inmates who are benefiting from discharge planning services “create an environment where people have hope,” says Rivera. This positive outcome will foster support for the program—both from the institution and from other inmates who may need the program’s services.

PEER EDUCATION

D It’s true what they say—there’s no better teacher than experience. That’s why many discharge programs incorporate peer education into their curriculums, because peers generally offer a cost-effective means of providing important lessons in HIV prevention and care within correctional facilities. Most peer educators are volunteers and come at no additional cost to the correctional facility or re-entry program provider. Peer educators can be inmates incarcerated alongside the inmates they are teaching, or they can be former inmates who have “been there, done that” and have the valuable experience of life both inside and outside prison walls—and the experience of successfully remaining outside prison walls. “That message is very different,” says Rivera.

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Creating Alternatives

Ryan White Program grantees and providers are charged with engaging PLWHA in medical care and sustaining them in care over time. With an HIV prevalence rate that is three times higher than that of the general population, the corrections population is an obvious place to seek out such clients. Doing so requires that HIV/AIDS service providers address gaps in services for this woefully underserved population.

Filling the gap in services for people being released from incarceration is not easy, and no provider—as experience indicates—should go it alone. A collaborative, mutually beneficial relationship with the corrections system is essential, as are strong relationships with providers of essential services like housing and substance abuse treatment. Strong relationships do not happen overnight.

Relationships, however, are just part of the picture. Supporting people who are returning to the community requires empathy and cultural competency. The employment of ex-offenders in many reentry programs reflects this sensitivity. In addition, successful programs require financial resources and the staying power to reach out over time to a population among whom the rates of falling out of care and recidivism are extraordinarily high.

The good news is that, with appropriate intervention, the cycle of incarceration can be broken, the untreated can be brought into and retained in care, and lives can be repaired. Ultimately, the solution lies in providing people with alternatives to the way of life that brought them to the prison gate along with supports like housing, education, and health care. Most important, HIV-positive ex-offenders need opportunities that enable them to remain ex-offenders.

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