APPENDIX: OUTCOME STATISTICS

California Department of Health

• A total of 65,436 inmates received prevention education from Centerforce under the CDP. Of those, 45,199 were offered HIV counseling and testing.
  
  
• Discharge planning was provided to 245 high-risk HIV-negative inmates; all but 1 inmate enrolled in and accepted postrelease community case management services. The majority of those receiving discharge planning were African-American (53 percent). Another 22 percent were Hispanic, and 20 percent were White.
  
  
• An outcomes-based behavioral study was conducted in a subset of 107 clients who participated in the community case management program.
  
  
• The extent of services received influenced client retention rates: 46 percent of releasees participated for at least 8 weeks, and 23 percent finished the entire community case management program. Almost one-third were lost to follow-up within the first 48 hours, an indicator of the need for stronger inmate–community agency interactions prior to release.
  
  
• Inmates who did not secure housing prior to release were significantly more likely to be lost to follow-up. Participants in the “Get Connected” program reported significantly less risk across several key indicators in the 30 days prior to the assessment:
  • Forty-three percent reported using drugs prior to incarceration; 0 percent reported injection drug use postrelease.
  • Twelve percent reported using condoms every time or most of the time prior to incarceration; 45 percent reported consistent condom use postrelease.
  • Forty-six percent reported using drugs during sex occasionally or never prior to incarceration; postrelease, this proportion rose to 86 percent.
    
    
• Approximately 130 inmates received prevention education services through Continuum’s community health resource fairs.
  
  
• Between February 1, 2001, and September 30, 2004, a total of 256 HIV-positive inmates received discharge planning in the San Francisco County Jail; 214 went on to receive community case management services after their release into the community.
  
  
• To evaluate the effectiveness of enhanced case management interventions for HIV-positive ex-offenders in the Homebase program, a randomized control trial (the San Francisco Department of Health HOPE Study) was carried out with 120 clients in the enhanced intervention and 120 in basic case management. Clients were followed for a total of 6 months. Preliminary analysis found the following results:
  • All but eight clients completed at least one postrelease follow-up interview.
  • Seventy-one percent of the clients in the enhanced intervention completed the 6-month follow-up, compared with 56 percent in the control group.
  • Fifty-two percent of the enhanced intervention group clients were reincarcerated by month 6, compared with 58 percent of the control group—a slight improvement.
  • Building relationships with participants during their incarceration in jail that continued in the community appeared to be the most important strategy to ensure postrelease follow-up.
    
    
• As part of HRSA/CDC supplemental funding received in the last 2 years of the CDP, the HOPE Study/Homebase participated in a multisite cost analysis evaluation with the Economic Evaluation Center at Emory University. Because the program included optional housing, the costs were assessed for the full program as well as for the program without housing. Findings were as follows:
  • Societal cost per client was $4,419 with housing and $3,453 without housing.
  • The full Homebase program would provide cost savings if it could avert 0.73 new HIV infections; the program with housing would provide cost savings if it could avert 0.57 new HIV infections. Both thresholds appear realistic.

Florida Department of Health

• The following services were provided in jail settings between February 2000 and September 2004:
  • 2,172 HIV educational sessions were provided.
  • 16,162 HIV tests; of those, 527 (3.3 percent) were positive. (A total of 176 prison inmates were tested; all tests were negative.)
  • 14,999 syphilis tests were conducted; 3.9 percent were positive.
    
    
• Between February 2000 and September 2004, 11,383 inmates were tested for both gonorrhea and chlamydia. A total of 487 (4.2 percent) were positive for gonorrhea, and 981 (8.6 percent) tested positive for chlamydia. Between April 2004 and the end of the project in September 2004, 2,833 chlamydia and gonorrhea tests were administered; 95 (3.3 percent) were positive for gonorrhea, and 119 (4.1 percent) were positive for chlamydia.
  
  
• A hepatitis screening and vaccination protocol was implemented in the Jacksonville/Duval Jail in January 2003. During the project, 2,900 inmates were screened; 410 (13.8 percent) tested positive for the hepatitis C antibody, and 587 (19.9 percent) were positive for the hepatitis A antibody. From January to November 2003, 988 doses of hepatitis B vaccine were given to 653 inmates.
  
  
• The Jail LINC Project served 867 HIV-positive inmates prerelease; 802 of those inmates received prerelease discharge planning. A total of 264 inmates were served postrelease from February 2000 to September 2004. In the prison program, 196 releasees were provided intensive case management and follow-up.

Georgia Department of Human Resources

• A total of 11,217 women were screened for chlamydia and gonorrhea; approximately 739 (7 percent) were found positive. Less than 50 percent (357) were treated and counseled prior to their release. Only 214 (2 percent) were positive for gonorrhea; 152 (more than 70 percent) were treated prior to release. Women ages 18 to 24 had the highest rates of chlamydia (48.8 percent) and gonorrhea (44.8 percent).
  
  
• A total of 9,767 juveniles (80 percent) admitted to the Metro Regional Youth Detention Center were tested for chlamydia and gonorrhea. Of those tested, 10.6 percent were positive for chlamydia and 3.8 percent were positive for gonorrhea. Treatment rates prior to release were 64 percent for chlamydia and 71 percent for gonorrhea.
  
  
• A total of 2,396 detainees participated in prevention education services at the Fulton County Jail. Fifty-three percent were male, and 83 percent were African-American. Only 2 percent of the detainees were of Hispanic descent. Single education sessions were provided to 206 participants over a 12-month period, and 2,190 detainees received multiple education sessions.
  
  
• A total of 2,611 men and women received prevention education sessions at the Jimmy Helms and Metro Transitional facilities. An average of 15 participants received one prevention education session per month over a period of 2 years at the two transitional facilities. During the CDP, 319 participants received a total of 26 individual sessions.
  
  
• 4,150 male and female juveniles received prevention education services at the Metro and DeKalb Regional Youth Detention Centers. Seventy-six percent were male, 85 percent were African-American, and 5 percent were of Hispanic descent. Single sessions were provided to 2,600 participants.
  
  
• About 1,013 adult clients received discharge-planning services at the Fulton County Jail; 431 of those clients were formally discharged under the CDP, resulting in more than 1,700 postrelease community case management encounters from 1999 to 2004. Medical care and housing were the largest referral and appointment categories, followed by drug treatment.
  
  
• Between January 2002 and July 2004, 97 inmates at the Fulton County Jail enrolled in intensive discharge-planning and postrelease case management services that included continuous follow-up for 6 months. Eighty-seven percent of the clients were HIV positive without AIDS. Most (88 percent) received a complete prerelease discharge plan. Of those, a total of 40 (47 percent) were accounted for 30 days after release. Their most mentioned needs were HIV care and medications, followed by cash, medical benefits, and housing. Sixty-five percent met their first scheduled appointment with their case manager. By the end of the CDP, 18 clients had successfully completed the full 6-month intensive postrelease program. Of those who did not, 14 percent were incarcerated; 9 percent had transferred to a permanent, long-term case management program; and 5 percent no longer wanted services. The remaining noncompleting clients (72.5 percent) were lost to follow-up. Eight of the 97 enrolled clients became aware of their HIV-positive status during their participation in the CDP.
  
  
• Georgia clients demonstrated moderate health care access, and 40 percent had access to HIV care. Access to medical care was cited by 50 percent as a problem. About 13 percent of clients had been diagnosed with major depression, and 3 percent had been diagnosed with bipolar disorder. Sixteen percent had taken or were taking medication for mental health conditions. More than 70 percent consumed alcoholic beverages prior to arrest. More than 80 percent reported having used illicit drugs prior to their arrest, and more than 30 percent had exchanged sex for money, drugs, or a place to stay.

Chicago Department of Public Health

• The Illinois Public Health Corrections and Community Initiative provided services to 2,028 clients seen by Cermack Health Services and the CORE Center Clinic. Of those, 159 clients received both AIDS Foundation of Chicago (AFC) and Cermack Health Center/CORE medical services in the community; 20 clients were prescribed HIV medications, 62 tested positive for hepatitis B, and 61 tested positive for hepatitis C.

Intensive case management services were provided at two sites (the Cook County Jail and AIDS Foundation Chicago):

• A total of 797 clients within the Cook County Jail received services; 455 were tested for HIV, and 3.3 percent were HIV positive.
  
  
• A total of 481 clients received intensive case management and transition services at the AFC. Most (79 percent) were male, and African-Americans comprised more than two-thirds (67 percent). Eleven percent were White, and nearly 11 percent of clients identified as Hispanic. Of the 481 clients, 295 (61 percent) were HIV positive; 17 percent (84) had confirmed AIDS. Transmission factors included heterosexual (49 percent), IDU (25 percent), men who have sex with men (12 percent), and unknown (17 percent). At the end of the project, 171 clients (36 percent) were still receiving AFC community case management, 112 clients (23 percent) had been reincarcerated, 92 cases (19 percent) were successfully closed and transitioned to Ryan White case management, and 66 clients (14 percent) could not be located. The rest (less than 7 percent) were hospitalized or had refused services.
  
  
• A hepatitis program was added in June 2002 with supplemental funding from the CDP. This program provided education and hepatitis B immunizations to adolescents who had signed parental consent forms. The program educated 5,798 adolescents in 12-hour sessions; clients were primarily African-Americans (80 percent) and Hispanics (17 percent).
  
  
• HIV prevention education services were provided to 1,051 adolescent females in the Cook County Juvenile Temporary Detention Center. The hepatitis program educated and vaccinated 358 adolescents in the 22-month program. HIV testing was provided to 483 females (46 percent); 0.4 percent tested positive.

Massachusetts Department of Public Health

• The Transitional Intervention Project (TIP) served 884 clients, representing 1,265 cases.
  • A total of 22,863 service-related events were documented during the CDP. More than half of the events (12,431) were in the case management category; 3,375 were arraignment appointments, 2,670 were case reviews, and 1,729 were intake assessments. A total of 1,035 cases were closed.
  • The clients consisted of 674 men (76 percent) and 210 women (24 percent).
  • Twenty-three percent of clients were African-American, 29 percent were Hispanic, 38 percent were White, and 10 percent were “other.”
  • Ten percent of clients were ages 17 to 29, 46 percent were ages 30 to 39, 37 percent were ages 40 to 49, and the remainder were ages 50 to 79.
    
    
• Clients (N = 636) identified the following areas as those for which they had the greatest need:
  • Medical/HIV care: 69 percent
  • Housing: 67 percent
  • Drug treatment: 58 percent
  • Basic needs: 46 percent
  • Transportation: 43 percent
  • Mental health treatment: 41 percent.
    
    
• A total of 702 assessments were conducted, representing 476 clients.
  • Eighty percent of the HIV-positive clients were receiving treatment for HIV during their incarceration; a different 80 percent planned to seek HIV care upon their release.
  • Transportation was identified by 46 percent as barrier to keeping medical appointments; 22 percent indicated that someone would need to accompany them.
  • More than 22 percent of clients had no insurance of any kind.
  • Forty-eight percent had a history of mental illness; 66 percent had received mental health treatment.
  • Ninety-six percent were substance abusers; 74 percent had received substance abuse treatment, and only 58 percent identified themselves as needing transitional substance abuse services.
  • Seventy percent of cases had only one housing option; 19 percent had no options; and for 34 percent, the nature of their offense would be an obstacle in finding housing.
    
    
• Closed cases included clients who had been released and were reincarcerated. A new case was opened if the client wanted services again upon release
  • Seventy-five percent of case management events were completed.
  • Ninety-three percent of appointments were kept.

New York State Department of Health AIDS Institute

Education Programs

• Prison-based: The AIDS Council of Northeastern New York (ACNENY) and the Altamont Program trained 400 adolescent inmates (ages 13 to 19) in State correctional facilities in upstate New York. AIDS Institute Bureau of Direct Operations staff and Rural Opportunities provided single and multiple HIV prevention education sessions to 16,468 inmates in both upstate and downstate New York.
  
  
• Jail-based: The Center for Community Alternatives (CCA) provided prevention education programs for HIV-negative women prior to release from the Onondaga County Jail and in the community postrelease; a total of 196 clients received multiple intervention sessions. The Osborne Association provided services to recently released inmates; 1,482 clients received prevention education and support services, and about 25 percent successfully completed the program.
  
  
• Juvenile: ACNENY and Altamont reached 1,132 juveniles in New York State Office of Children and Family Services group homes and residential settings. ACNENY trained 61 nurses and physician assistants in HIV stage-based behavioral counseling.

Disease Screening

• Prison: 3,267 inmates received HIV counseling and testing services; 40 (1.22 percent) were HIV positive, and 27 (67.5 percent) of those who tested positive were newly diagnosed cases of HIV. All were referred to medical assessment and treatment.
  
  
• Juvenile: 4,896 male adolescents were screened for STIs; 27 cases of gonorrhea (0.55 percent) and 123 cases of chlamydia (2.51 percent) were identified. All cases received treatment.

Discharge Planning and Transitional Services

• Jail: The Riker’s Island officer provided new inmate orientations addressing HIV discharge-planning and other jail-based and community services to 4,106 inmates. Discharge-planning services were provided to 994 inmates (874 at Riker’s and 120 at Onondaga County). Of those, 361 (261 from Riker’s Island and 100 from Onondaga County) were enrolled in community-based case management programs.
  
  
• Baseline interviews were completed for 222 participants:
  • A total of 62.2 percent were male, 59 percent were Black, and 68 percent were non-Hispanic.
  • Eighty-nine percent were HIV positive.
  • A total of 204 clients (91.9 percent) received case management services:
    • 88.7 percent received one meeting with a case manager.
    • 78.4 percent received some discharge-planning services.
    • 27.0 percent participated in individual or group HIV prevention education.
    • 54.9 percent were transferred and no longer received CDP services.
    • 81.8 percent (of 110 inmates remaining) received an appointment or referral for services in the community.
  • Referrals were provided for mental health services (77.3 percent), substance abuse treatment (62.7 percent), HIV/AIDS treatment (57.3 percent), and housing (50.0 percent).

New Jersey Department of Health and Senior Services

Staff Training

• New Jersey concentrated its training efforts on CBO staff training; 83 percent of staff trained were CBO staff. Juvenile staff received a 1.5-hour session on HIV, STIs, and modes of transmission.
  • Staff trained: 449 (373 CBO staff)
  • A total of 336 single and 276 multiple sessions
  • A total of 3,427 training hours.

Peer Education

• Once inmates got over the fear of being labeled as HIV positive (overcome by including HIV-positive peers), they welcomed the program and promoted it to other inmates. Of those recruited to be peer educators (N = 139), 93 percent (129) completed training, 30 percent of whom were women. Seventy percent of the trainees were Black, 14 percent were Hispanic, and 16 percent were White. The Division of Young Adult Medicine of the University of Medicine and Dentistry of New Jersey provided peer education in the juvenile facility four to six times each year.

HIV Prevention Education

• A total of 1,585 single prevention and education sessions, for a total of 32,975 inmates, took place in the 13 facilities. Nineteen percent of the sessions were peer led, and 5 percent were in Spanish. A total of 292 multisession prevention and education trainings took place, totaling 623 sessions; 9,537 of 11,724 (81 percent) completed the series. Peers led 48 percent of the sessions, and 14 percent of the sessions were in Spanish. The CBO held multisession health education/risk reduction classes in the juvenile unit that housed inmates; single-session classes were held in the other housing units. By the end of 2002, all 13 correctional facilities had HIV prevention and education and risk-reduction classes.

Disease Screening and Treatment Programs

• New Jersey screened and tested only for HIV under CDP’s disease-screening and treatment component. By the end of 2002, HIV counseling and testing services were available at all facilities.
  • A total of 9,807 inmates were tested for HIV; of those, 134 (1 percent) were HIV positive and 69 (51 percent) of those testing positive were new positives.
  • Seventy-nine percent received partner notification and referral services.
  • Of the 134 HIV positives, 126 (94 percent) were referred for HIV care and treatment, and of those, 26 (21 percent) were treated for AIDS.

Discharge-Planning Programs

• No services existed except at the Monmouth Jail prior to the CDP. Discharge needs were noted when clients enrolled in the CDP, and discharge planning was geared toward those needs. Services included links to HIV treatment and medications; mental health treatment and medications; substance abuse treatment; assistance with benefits applications (including ADAP and other health insurance); community case management for HIV-positive clients; basic needs such as food stamps, housing, and clothing; and identification.
  • A total of 1,920 inmates were served prior to release, of whom 9 percent were repeat clients.
  • A total of 1,497 inmates (78 percent) were released.

Community Transition

• Before the CDP, few services were available in the communities for released inmates. The CBOs found that community agencies were initially hesitant about follow-up and case management, but over time, they became receptive.
  • A total of 1,492 releasees participated in discharge planning; 829 (56 percent) participated in CDP case management.
  • Of those participating in CDP case management, 756 (91 percent) participated in postrelease case management. A total of 737 (89 percent) cases were successfully closed.

New Jersey Cohort: Program Impact on Client Health Outcomes

The New Jersey Cohort database contained 314 clients who were a subset of the New Jersey CDP database of 487 clients. This database was created to follow the same clients as much as possible from entry through completion of the CDP. Following each client using the unique identifier on CDP enrollment forms was not possible in the time allowed. Findings from the cohort provided a more detailed portrait of client-level needs and service outcomes.

Demographics

• The cohort of 314 clients was 76 percent male and 22 percent female.
  
  
• English was the primary language for 84 percent of clients; Spanish was the primary language for the remainder.
  
  
• Ninety-three percent were in prison, and the remainder (7 percent) was in jail.
  
  
• Five percent were ages 20 to 29, 41 percent were ages 30 to 39, 44 percent were ages 40 to 49, 8 percent were ages 50 to 59, and 1 percent were age 60 and older.
  
  
• Twenty percent were Hispanic, 17 percent were White, 66 percent were Black, 2 percent American Indian, and 13 percent were “other.”
  
  
• Sixty-six percent had a grade-school education, and 68 percent had never been married. At the time of arrest, 28 percent were working full time and 11 percent had part-time or odd jobs.

HIV Status

• At incarceration, 85 percent of the 314 cohort inmates were HIV positive, 58 percent of those who were HIV positive had an HIV care provider, and 42 percent were taking HIV medications. The level of educational sessions increased throughout the CDP. Eighty-one percent of the attendees in the multiple-session prevention and education series completed the full series.
  
  
• The CDP provided encouragement and the opportunity to get tested for HIV. Inmate influence also was a major factor in other inmates’ attending educational sessions and being tested. At release:
  • Eighty-five percent of the cohort were HIV positive, and 74 percent of those who were positive were on HIV medications (91 percent of those on medication were released with a supply, and 6 percent had a prescription).
  • Fifty-four percent of those who were HIV positive had a specific HIV care provider appointment, and 24 percent had referrals for HIV care.
  • At 1 month postrelease, more HIV-positive clients had an HIV health care provider and had gone to their first appointment than had an HIV care provider at arrest (79 percent vs. 58 percent). More clients were on medications at 1 month postrelease than at arrest (73 percent vs. 42 percent).
  • At 6-month follow-up, more than 92 percent of HIV-positive clients had seen an HIV care provider. HIV-positive clients, for the most part, remained in care.

Mental Health

• At incarceration, 35 percent of the cohort inmates had a significant mental illness (most commonly, depression [48 percent]). Of clients with mental illness, 57 percent had a mental health provider and 45 percent were on medication for their illness.
  
  
• At release, 35 percent of cohort clients still reported a significant mental illness, but the proportion with depression had dropped to 42 percent. At the time of release, all inmates with a significant mental illness had received treatment and medications and were set to continue with care and treatment in the community.
  
  
• At 1 month postrelease, the number of clients reporting depression had increased from 48 to 66 percent, and fewer clients (47 percent) reported having a mental health provider. CBO case managers indicated that adherence to mental health treatment was very important in HIV care compliance and retention in the program.
  
  
• At 6 months, 40 percent reported some form of mental illness, but 60 percent had a mental health provider and more than 50 percent were on medication, an improvement from their status at arrest.

Substance Abuse

• Substance abuse was a problem for clients in the CDP cohort:
  • At intake, 59 percent reported drinking alcohol and 79 percent reported street drug use in the days prior to arrest. The common reasons clients gave for not seeking drug treatment were alcohol and drug use, not wanting treatment, having dropped out of treatment, and other reasons. However, 40 percent had attended some type of treatment program in the 6 months prior to arrest (most often, detox and either drug or alcohol self-help or 12-step programs). Drug treatment was identified at intake as a discharge need for 69 (22 percent) of the 314 cohort inmates.
  • At release, 25 releasees had specific appointments for treatment, and the remainder had referrals. A higher percentage attended substance abuse treatment at 1 month postrelease than prior to arrest (52 percent vs. 40 percent).
  • At 6 months postrelease, the number of clients attending treatment had increased to 59 percent of those still in case management. Adherence to substance abuse treatment regimens was the second most significant health condition affecting retention.

Other Health Concerns and Case Management

• Of additional medical diagnoses noted for the 293 clients released, the most common were hepatitis C (41 percent), drug use and abuse (38 percent), and alcohol abuse (14 percent). Other diagnoses included asthma, diabetes, syphilis, TB, hepatitis B, and other STIs.
  
  
• Of the 293 cohort clients, 47 percent were met at the gate by the CBO case manager, 28 percent by family or a friend, 20 percent by no one, and 6 percent by an unknown person. More than 67 percent of the released clients had specific appointments with their case mangers, and 22 percent had referrals. They also had referrals or appointments for other services, as follows:
• Housing or shelter: 37 percent appointments; 28 percent referrals for shelter
• Non-HIV health care: 8 percent appointments; 20 percent referrals
• Mental health: 38 percent appointments; 51 percent referrals
• Substance abuse treatment: 36 percent appointments; 74 percent referrals
• Transportation assistance: 23 percent appointments; 39 percent referrals
• Basic needs: 23 percent appointments; 39 percent referrals
• Educational assistance: 5 percent appointments; 27 percent referrals
• Employment assistance: 11 percent appointments; 33 percent referrals
• Medical benefits: 30 percent appointments; 35 percent referrals
• Financial assistance: 14 percent appointments; 39 percent referrals.
  
  
• At 1 month postrelease, 73 percent of clients had attended their first case manager appointment. At 6 months postrelease, 93 percent of the 194 remaining clients indicated that they had a case manager in their correctional facility; the same proportion also had a case manger in the community. Ninety-eight percent of clients considered community case managers to be helpful, and 49 percent reported that the case manager was extremely helpful.