THE CORRECTIONS INITIATIVE

From 1999 to 2004, HRSA and the CDC jointly funded a national corrections demonstration project in seven States (California, Florida, Georgia, Illinois, Massachusetts, New York, and New Jersey). The HIV/AIDS Intervention, Prevention, and Continuity of Care Demonstration Project for Incarcerated Individuals Within Correctional Settings and the Community, known nationally as simply the Corrections Demonstration Project (CDP), involved jail, prison, and juvenile settings. The program targeted inmates with HIV/AIDS, hepatitis B and C, TB, substance abuse, and STIs. It supported an array of services that included treatment for HIV and other diseases in correctional facilities; discharge planning; case management to link clients to services following release; and, in two States (California and New Jersey), prevention case management for high-risk, HIV-negative releasees.

The CDP was an effort to develop effective collaborations with corrections systems, the community, and public health systems. It promoted partnerships among State and local health departments and CBOs and AIDS service organizations that were contracted by the grantee to provide services. The project provided services to thousands of inmates and generated a tremendous amount of data and information. That information is now being used to develop collaborative efforts in other parts of the country.

The goal of the CDP was to increase access to health care and improve the health status of incarcerated and at-risk populations, especially African-Americans and other racial minorities disproportionately affected by the HIV/AIDS epidemic. Major objectives were as follows:

• Increase access to HIV/AIDS primary health care and prevention services
• Improve HIV transitional services between corrections and the community
• Develop organizational supports and linked networks of comprehensive HIV health and social services.

The initiative targeted people in correctional settings; the primary objective was to extend inmates’ medical care and support services to the community to which they were returning upon release. Correctional settings included prisons, jails, detention centers, and transitional halfway houses. The target population included African-Americans detained in the criminal justice system, especially jails and juvenile detention facilities. Projects were to develop collaborations between correctional settings and community-based health care and support service providers that would support continuity of health care and provide ancillary and supportive services to effect positive behavioral change, increase health care access, and improve health status.

Models of linked networks of health services, including prevention and treatment of HIV/AIDS, STIs, TB, hepatitis, and substance abuse during and after incarceration, were to be developed and evaluated for replication by other primary care, prevention, criminal justice, and community service organizations. The CDP sought to create a combination of services, including surveillance, medical and behavioral screening and assessment, prevention education and counseling, primary health care, and referral linkages. Its multitiered focus included providing services in jails, prisons, juvenile detention centers, and transitional halfway houses; working within correctional and community-based systems of care; and implementing long-term, systemic change. Special emphasis was placed on working with jails and juvenile detention facilities because of their direct linkages to the community.

This initiative was a competition limited to 11 States (California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Texas) and the District of Columbia.

These locations were identified as priority areas because they represented

• 56.2 percent (635,483) of the total prison population for 1997,
• 74.7 percent (76,679) of all AIDS cases among African-Americans for 1997,
• 82.7 percent (19,361) of all HIV-positive inmates in State prisons, and
• 26 of the 30 Metropolitan Statistical Areas where AIDS had the greatest impact on African-Americans.

Funding priority was given to applicants that offered the greatest potential to increase access to prevention and primary health care and improve the health status of incarcerated and at-risk African-Americans and other racial and ethnic minorities. The funds were part of a larger pool of resources targeting the AIDS epidemic that was made available as a result of activities initiated by the Congressional Black Caucus in response to a state of emergency issued in 1998 by the caucus and CDC. Approximately $7 million was available to fund five to eight demonstrations for a project period of 3 years. This period was later expanded to 5 years. The application stipulated that at least 40 percent of the provided funds be directed to community-based prevention, primary care, and other ancillary service providers to support and develop models of linked networks of health services. Services would include prevention and treatment of HIV/AIDS, STIs, TB, hepatitis, and substance abuse during and after incarceration.

HRSA and CDC provided technical assistance, staff development, and onsite evaluation consultants to ensure that the projects would have the technical support and assistance needed to undertake the outlined activities. To ensure the definition and measurement of appropriate project outcome measures, HRSA and CDC issued a separate request for proposals to identify and select an evaluation support center (ESC). The role of the ESC was to work collaboratively with the projects to develop a data collection plan that included data collection instruments and procedures. The ESC was to produce a series of formative cross-program evaluations to identify and describe (1) program components critical to health-seeking behaviors among previously incarcerated people, (2) the costs associated with program interventions in and outside correctional settings, and (3) lessons learned (issues of local governance, management strategies, development and implementation of intervention models, etc.). Each project would analyze its own outcome indicators to monitor and support program management and evaluation.

Health departments from six States (California, Florida, Georgia, Massachusetts, New Jersey, and New York) and one city (Chicago) were awarded funding from CDC to implement their projects in prisons, jails, juvenile facilities, and related correctional settings. HRSA’s SPNS program funded the Emory University Rollins School of Public Health (Atlanta, GA) and its collaborator, Abt Associates (Cambridge, MA), to coordinate the evaluation of the initiative. Three additional organizations were funded by HRSA and CDC as technical assistance providers for the grantees and their subgrantees or contractors: the National Minority AIDS Council (Washington, DC), the Southeastern AIDS Training and Educational Center (Atlanta) and the Hampden County Correctional Facility (Public Health Model of Correctional Care; Ludlow, MA). Funds were awarded at the end of September 1999, and the project began that October.

Each of the seven CDP grantees received approximately $1 million per year to conduct continuity-of-care service activities for HIV/AIDS. A few sites’ existing activities were enhanced by CDP funding, whereas others were able to implement new services within correctional settings. By early 2001, an assessment compiled for the annual grantee meeting revealed that services were being provided in 24 jails, 48 prisons, more than 100 juvenile justice facilities, and 26 community corrections settings. The cross-site activities fell into eight categories:

• HIV/AIDS clinical evaluation and treatment
• HIV/AIDS prevention education
• Peer education
• Disease screening, counseling, and testing
• Staff development and training
• Discharge planning
• Continuity-of-care case management
• Prevention case management.

Considerable variability existed within each category and within each correctional setting.

The CDP grantees provided ample resources and technical support, but local political environments, the lack of trust between corrections and public health, and cumbersome fiscal and management policies plagued all projects to some extent during the first year. As a result, it was not until mid-2000 that basic services were sufficiently in place to begin quantitative data collection on critical process indicators.

The following section provides aggregate data from all CDP grantees according to service category and facility type. The data reflect the services supported by the CDP and tracked by the ESC; they do not reflect the comprehensive array of services that each grantee provided in participating correctional facilities. Many grantees saw this initiative as an enhancement of existing services, whereas others used CDP resources to plan and implement services where none were previously available. As a result, cross-site evaluation data do not reflect the true extent of efforts that were provided during the duration of the project.