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Background
Project START History
How is this project unique?
Formative Research
Formative Research Key Findings
Behavioral Intervention Trial
Intervention Key Findings
Lessons Learned–Challenges of Prison Research
Main Findings
- Project START’s Enhanced
Intervention was successful: men in the Enhanced
Intervention had lower rates of sexual risk 24 weeks
after release compared to men in the Single Session
Intervention.
- Young men leaving prison are at
risk for HIV, STD and hepatitis.
- Many young men leaving prison
engage in unprotected sexual activity immediately after
release from prison.
- Young men leaving prison are also
at high risk for returning to prison.
- It is feasible to maintain contact
with young men after they have left prison when there
are sufficient resources for tracing.
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Background
By the end of 2002, over 2 million adults were
incarcerated in the US, and 93% of those were men. African Americans
and Latinos were incarcerated at greater rates than Whites in the US,
7.6 times greater for African Americans and 2.6 times greater for Latinos.
Nearly 40% of incarcerated men were under the age of 30. Young men of
color are at high risk of incarceration and the health problems related
to incarceration.
These young men also are our neighbors, frequently
passing in and out of jail and prison and returning back to the community.
Men who are incarcerated have disproportionate rates of HIV, sexually
transmitted diseases (STDs) and hepatitis. Rates of HIV are 8-10 times
higher for incarcerated persons than for the general US population;
hepatitis C rates are 9-10 times higher, and STD rates among men entering
jails are as high as 35%.
Men leaving prison face numerous challenges that
may impede their ability to protect themselves against these diseases.
Men often must re-establish relationships, find employment and housing
and deal with addictions and mental health issues. Prisons present a
unique opportunity for HIV/STD education and skills building to help
men avoid risk after their release from prison.
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Project START History
There are few services for men leaving prison and
little research on HIV/STD prevention programs for men leaving prison.
Recognizing the need to develop and test interventions specifically
for incarcerated men, the Centers for Disease Control and Prevention
(CDC) funded Project START to develop an HIV, STD and hepatitis prevention
program for young men aged 18-29 who are leaving prison and to test
the effectiveness of the interventions in reducing sexual risk after
leaving prison. Study sites at state prisons were selected in four states:
California, Mississippi, Rhode Island and Wisconsin.
The first three years of the study were dedicated
to formative research. During the formative research period, all investigators
engaged in a process of intervention development to create a Single
Session Intervention (SSI) and Enhanced Intervention (EI). The intervention
was implemented through a behavioral trial where the SSI and EI were
compared and participants were followed for six months after their initial
release from prison.
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How is this project unique?
- The interventions were designed specifically
for young men (18-29 years) leaving prison.
- The EI started pre–release and continued post–release.
- The interventions were based on extensive formative
research with incarcerated men and providers both inside and outside
of prison.
- The interventions focused on sexual risk, with
reincarceration as a secondary outcome.
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Formative Research
Our formative research included three studies.
First, we conducted qualitative research with 71 service providers working
inside the prison and 97 working outside the prison. Providers inside
prisons included wardens, correctional officers, teachers, nurses, physician
assistants and chief medical officers. Providers outside the prison
included staff from various services including HIV/STD, homeless, halfway
house, medical and mental health, substance use, parole officers, faith-based
personnel and vocational counselors.
Second, we conducted qualitative and quantitative
research with 106 men, recruiting them while incarcerated and conducting
interviews prior to release and at 1, 4, 12 and 24 weeks after release.
Third, we collected urine and blood samples from
these men when they had been out of prison for 24 weeks to assess the
feasibility of testing for STD and hepatitis among this population.
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Formative Research Key
Findings
Provider Perceptions of Risk
- Providers believed most men were sexually active immediately after
release. They did not believe abstinence was an effective intervention
outcome for sexual behavior.
- The most likely reason for HIV/STD risk was believed to be sexual
activity combined with drug use.
- Reasons for sexual risk behavior included: “making up for
lost time,” “being a man,” degree of HIV/STD knowledge
and vulnerability, desire to escape and lack of future orientation.
- Peers, partners and family had a strong influence on risk behavior,
both positively and negatively.
- Factors that could help reduce risk were: stable housing, availability
of jobs and economic self sufficiency; and positive community support
including needle exchange services, drug treatment and condom distribution.
Conclusion: Providers believed that an
intervention that focuses directly on sexual risk reduction in the context
of men’s lives as they reenter the community after release was
most likely to be effective.
Risk Behavior of Men Leaving Prison
- Men engaged in unprotected sexual activity soon
after release from prison, with 51% engaging in unprotected sex on
the first day and 86% by the end of the first week.
- Rates of reincarceration were high: 72% had
at least 4 prior incarcerations and 40% spent at least one day in
prison or jail in the 24 weeks since their initial release.
- One-third of the young men reported they had
ever been diagnosed with an STD, 2% were hepatitis C positive and
2% were HIV+.
- Most men had primary committed female partners.
Only 8% consistently used condoms with their primary partners prior
to incarceration.
- 1% reported sex with men.
- Almost 10% reported ever injecting drugs.
- After release, two-thirds used alcohol and half
used marijuana, even though many were on probation or parole.
- Half of the men were unemployed prior to incarceration,
80% at 1 week post-release and 40% at 24 weeks post-release.
Conclusion: Young men faced many challenges
after release. Programs should be comprehensive by focusing on HIV/STD
and hepatitis risk as well as the context of risk and immediate needs
of men post-incarceration.
Feasibility of STD and Hepatitis Testing
- Collecting specimens and providing results is
feasible. Monetary incentives can increase participation.
- Of 33 men tested for STDs and hepatitis, 8 (24%)
had Chlamydia, Trichomoniasis, HBV or HCV.
Conclusion: STDs are common among these
men. Programs for men who have been incarcerated should be aware that
many men acquire infections after release from custody and should be
referred for screening, treatment and vaccination for STDs.
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Behavioral Intervention
Trial
Development
The intervention was designed based on the formative
research we conducted with prison service providers and incarcerated
men. Formative research helped us understand what the differences were
in each state’s prison system, what would work within the structure
of the prisons and whether it was possible to recruit men in prison
and maintain contact with them after release.
We formed a committee with representatives from each research site to
develop the intervention and intervention materials, pilot-test the
intervention and refine the intervention prior to the randomized behavioral
trial. We also developed referral lists and community resource guides
for each site.
We hired interventionists and interviewers who
had experience working with incarcerated populations. Each project staff
member had to be cleared by the state’s Department of Corrections.
We held two cross-site trainings prior to implementation. Intervention
staff received follow-up trainings and regular supervisory meetings
at each site.
Process
The Project START intervention trial involved 522
young men between the ages of 18 and 29 (52% African-American, 23% White,
14% Hispanic, 12% other). Men were recruited from eight state prisons
in four states: California, Mississippi, Rhode Island, and Wisconsin.
We used non-biased assignment to either an SSI prerelease or an EI.
The EI included the two pre-release sessions and four individual sessions
post-release. See Diagram 1 for the intervention design.
Although men were not paid to attend intervention
sessions, they were provided with transportation and/or child/elder
care reimbursement up to $10 if applicable. Men were also offered free
condoms and resource and educational materials at all post-release sessions
that did not occur in a prison or jail. Participants were paid for completing
each assessment session and were provided with pagers and voicemail
to assist project staff in maintaining contact after release.
The intervention was based on the following conceptual
framework:
Harm Reduction: reducing harmful
consequences to participant and others.
Problem Solving: generating possible
solutions, determining consequences, choosing best solution, creating
a realistic plan of action.
Motivational Enhancement: enhancing
motivation for behavior change through a client-centered
but directive approach.
Enhancing Access to Services:
facilitating referral and reducing barriers to use of existing community
services.
Single Session Intervention (SSI)
This intervention took place about 2 weeks prior
to release and lasted 60-90 minutes. Young men met individually with
a trained interventionist. Together, they assessed the young man’s
HIV/STD/hepatitis knowledge and risks, and then devised a personalized
risk reduction plan. See Sidebar 1 for a composite case example.
Sidebar 1: SSI Composite
Case Example
Joe Jones was recruited as he neared
the end of his three-year sentence. He was 21 years old,
unmarried and planned to return to live with his parents
in a rural area of the state. Due to his recruitment date,
he was assigned to the SSI. In the intervention session
Joe worked with the interventionist to review his knowledge
about HIV, STDs and hepatitis and to identify his own risk
(risk assessment). After this review Joe and the interventionist
agreed that his primary risk was through unprotected vaginal
and anal intercourse with casual female partners, particularly
when he had been drinking or using drugs. The interventionist
worked with Joe to identify barriers to condom use and to
make a specific behavioral plan to have condoms available
when going out to meet women. Joe acknowledged that his
alcohol and drug use contributed to his risk and although
he was skeptical about needing alcohol or drug treatment
services, he accepted referrals from the interventionist.
At the end of the session, Joe received a written copy of
his goals and risk reduction plan. At 24 weeks post-release,
Joe reported using condoms more consistently.
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Enhanced Intervention (EI)
Two sessions of this multiple-session intervention took place in prison
prior to release, and four sessions were planned after release at 1,
3, 6 and 12 weeks post-release. The first in-prison session was the
same as the SSI. The second in-prison session focused on the participant’s
needs after release and included assessment, planning, problem-solving,
and facilitated referrals for housing, employment, financial problems,
social relationships, substance use and mental health treatment, legal
problems and avoiding reincarceration. Together, they created a participant
plan.
The post-release sessions continued the plan developed
during the in-prison session. In each session, the participant and interventionist
assessed previous plans and goals, problem-solved difficulties, and
focused on new goals identified by the participant. Each session included
a review and update of the HIV/STD/hepatitis risk reduction plan developed
in the first session. All sessions ended with an updated plan that addressed
post-release needs and used existing community resources where available.
See sidebar 2 for a composite case example for the EI.
Sidebar 2: EI Composite Case
Example
John Smith was recruited 60 days prior
to his release from a two-year sentence. He was 27 years
old, unmarried and planning to return to live with a friend
after release. Due to his recruitment date, he was assigned
to the enhanced intervention. In the first intervention
session Joe worked with the interventionist to review his
knowledge about HIV, STDs and hepatitis and to identify
his own risk (risk assessment). John and the interventionist
agreed that his primary risk was through unprotected vaginal
intercourse with the mother of his two children who was
a regular but not committed sexual partner. They developed
a plan to support John in introducing condoms into this
relationship. In the second session prior to release John
worked with the interventionist to define broader post-release
goals. In this process John prioritized finding work and
realized that renewing his driver’s license and developing
a resume were the first steps toward this goal. He developed
a step-by-step plan toward these goals, discussed his immediate
post-release plans and scheduled a time and place to meet
for the first post-release session. John met with the interventionist
three times post-release. He missed his third post-release
session when he was briefly re-incarcerated due to a parole
violation. By the final post-release session John has enrolled
in an employment development program and had successfully
negotiated condom use with his regular partner. |
Evaluation
Young men answered survey questions to assess risk behavior prior to
release and at 1, 12 and 24weeks after release. Retention was excellent,
with 83% of men completing the 24-week follow-up assessment. In three
sites (MI, RI and WI), assessments were conducted using audio-computer-assisted
self-interview (A-CASI) technology. In one site (CA), the use of laptop
computers for research was prohibited in the prison and all assessments
were conducted face-to-face. Young men were reimbursed for participating
in the evaluation, with the amount varying by cost of living in each
state ($180-$200 if all assessments were completed).
Some post-release assessments were conducted by
telephone when it was not possible to conduct an in-person assessment.
Assessments were conducted in prison for participants who were reincarcerated
and at a variety of community sites for participants who were released.
In-prison assessments did not include questions about sexual behavior
or substance use that occurred during that incarceration. For each participant,
one staff member delivered the intervention and a second staff member
conducted the assessments.
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Intervention Key Findings
Project START is at the beginning of its analysis
stage and these findings are just the beginning. We are continuing to
analyze our results and expect to have more detailed data on sexual
risk behavior and reincarceration by the end of 2004.
Reduction in Sexual Risk Behavior
- At 24 weeks, men in the EI (68%) were significantly
less likely than men in the SSI (78%) to report unprotected vaginal
or anal sex with all partners since the last interview. This effect
was driven by differences in risk with main partners (as opposed to
non-main partners).
- Many men had main and non-main partners who
were themselves at increased risk of HIV/STDs or hepatitis.
Conclusion: These men were at considerable
risk for sexually transmitted infections before and after incarceration.
Greater risk reduction occurred with main partners than with non-main
partners, protecting not only the men but their partners as well. The
Project START intervention was effective in reducing sexual risk behavior.
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Lessons Learned–Challenges of Prison Research
Feasibility of Research in Prison Systems
- Working in prisons presents numerous challenges
such as: postponing work during lock downs, needing clearance by the
Department of Corrections for all project staff, locating an appropriate
private space for interviews and interventions and complying with
prison regulations.
- Despite all this, Project START conducted formative
research, developed interventions, recruited over 500 men at 8 prisons
across 4 states, conducted interventions both inside and outside the
prison and had excellent retention rates.
Needs of Incarcerated Men
- HIV/STD intervention programs for incarcerated
men who are being released should address strategies to reduce risk
behaviors associated with HIV/STD transmission, and other needs like
housing, employment, mental health issues and reintegration with family.
- These intervention programs should cover the
period from pre-release to reentry into the community.
- The first weeks post-release are crucial. Risk
behavior resumes soon after release.
- Programs need to go beyond simply providing
community referrals, to making facilitated referrals (locate “friendly”
agencies and staff, call the agency and make the appointment, follow-up
to make sure appointment is kept).
Recruitment and Retention
- Recruitment and retention for research studies
is feasible if you learn the prison system and work within it.
- It is possible to maintain contact with men
post-incarceration. It is resource-intensive and requires dedicated,
well-trained staff.
- Young men experience high rates of incarceration.
Programs should develop relationships with correctional institutions
that allow them to maintain contact with participants who are reincarcerated.
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