# Presentation: 321335

## HIV & HCV Prevention: Intervening at the Prison Gate

- James A. Inciardi, Daniel J. O’Connell, Hilary L. Surratt, & Steven S. Martin
- Center for Drug and Alcohol Studies
- University of Delaware

- Drug Abuse and Risky Behaviors:
- The Evolving Dynamics of HIV/AIDS
- Bethesda MD, May 8-9, 2007

## Cooperative Agreement Mission

_**Cooperative Agreement Mission**_
-  	Establish a national research network to test different integrated system-level drug abuse treatment models for drug-involved criminal justice populations.
-  	Facilitate knowledge development about drug treatment services that can improve offender outcomes.

## Slide 3

## Slide 4

## CJ-DATS HIV-HCV Project

- Lead Center
- University of Delaware
- Other Participating Centers
- University of Kentucky
- Virginia Commonwealth University

## Statement of Problem

- HIV seropositivity rates in U.S. prisons are estimated to be 8 to 10 times higher than those in the general population.
- The prevalence of Hepatitis C (HCV) infection among prisoners ranges from 16% to 41%.
- Approximately 650,000 prison inmates are released to the community each year.
- The risk of death during the first two weeks after release from prison is 12.7 times higher than that in the general population.

## Primary Objectives

- Develop a brief, cost effective HIV-HCV intervention that has the potential for large scale technology transfer and is accessible to re-entry populations.
- Implement and evaluate the effectiveness of a new peer-facilitated, interactive, DVD-based HIV-HCV intervention protocol, as compared to:
- the NIDA “Standard Intervention”
- “current practice” in contemporary correctional institutions.
- Estimate the prevalence of HIV and HCV in samples of re-entering offenders.

## Intervention Format

- Peer interventions have been successful in changing health risk behaviors.
- Peer interventionists have credibility with the target population.
- DVD format:
- Allows for video testimonials of offenders of the same race and gender as the client.
- Insures greater fidelity to the intervention.
- Permits large scale and inexpensive technology transfer.

## Intervention Timing

- Logically, the re-entry period is a pivotal time in which intervention efforts have the greatest potential for significant impact.
- Research has shown that:
- HIV and HCV risk behaviors engaged in prior to incarceration typically resume and/or increase after release from the institution.
- Many offenders attempt to “make up for lost time” when released, which involves seeking out and engaging in risky sexual behavior and drug use.

## Intervention Development

- Focus groups were conducted with members of the target population to better understand the barriers to safe sex and drug use among re-entering offenders.
- Based on this input, elements of existing, effective interventions were modified for appropriateness for the offender subculture.
- Video testimonials and scenarios were incorporated to reflect the experiences of re-entering offenders and to represent the risky situations they will likely confront in the community.

## Pilot Test

- DVD interventions were delivered to offenders in  re-entry in Delaware to gauge acceptability and appropriateness.
- Participants found the intervention engaging, insightful, and meaningful.
- Many were actually “rooting” for the people in the drug and sex scenarios to do the right thing.
- Having healthy looking HIV and HCV positive offenders talk about contracting the disease was powerful.

## Study Design

**Study Conditions:**

**HIV Educational Video, Recruitment**

**Education Only**

**NIDA Standard**

**CJ-DATS Targeted**

**Health Practitioner **
**Administered NIDA **
**Standard Intervention**
**HIV/HCV Testing**

**Peer **
**Administered, DVD**
** ****Based Intervention**
**HIV/HCV Testing**

**HIV/HCV Testing**

**Screening, Informed Consent, Baseline Interview, Randomization**

**2 weeks later, Second Session**
**Post Test Counseling**

**2 weeks later**
**Post Test Counseling**

**2 weeks later**
**Post Test Counseling**

**30 & 90 Days later**
**Follow Up Interviews**

**30 & 90 Days later**
**Follow Up Interviews**

**30 & 90 Days later**
**Follow Up Interviews**

## The Targeted Intervention Process

- The peer interventionist guides the presentation, assists and engages the client, answers questions, and relates the material to the client’s own experiences.
- The combination of message (offender-focused), messenger (peer), and mode (DVD) are expected to strengthen the efficacy of the intervention among re-entering offenders.

## CJ-DATS Targeted HIV-HCV Intervention Timeline & Delaware Site Progress

## Baseline Data

- As of April 1, 2007, the Delaware site had  completed 147 baseline interviews

-  47% high school grad.
-  60% 10 or more arrests
-  Mean age = 31.6 years

## Drug Risk Behaviors

- In the six months prior to current incarceration:
- 8% injected drugs
- 33% of IDUs shared needles
- 5% injected daily

## Sexual Risk Behaviors

- In the 30 days prior to the participants’ current incarceration:
- Over 80% had unprotected sex
- Mean of 28 times, max of 200 times
- Percent having unprotected sex:
- 40% with someone other than a main partner
- 4% with an IDU
- 15% with a crack user
- 9% with a sex trader
- 67% had unprotected sex while high

## Percent HIV and HCV Positive (n = 126)

## Continuing Progress

- Kentucky has been in the field since January.
- Virginia team estimates initial recruitment during May.
- Delaware and Kentucky 30-day follow-up data analyses will commence in late May.

## Correctional Challengesto Implementation

- Some correctional systems are resistant to peer-based interventions because:
- Some do not consider public health to be part of their mission.
- Many do not allow “peers” in their institutions.
- Many consider the inmate population to be undeserving.
- Interventions require more work from staff -- scheduling, locating space, moving inmates.

## “Inmate Culture” Challengesto Implementation

- The inmate culture glorifies anti-social thoughts, feelings, and behaviors.
- Many inmates engage in anti-social behaviors while incarcerated.
- Inside the institution, “props” or respect is typically reserved for the most cunning, the most anti-social, and the most violent offenders.

## Impact of the Inmate Culture

- The inmate culture often puts offenders in a mental relapse mode before they are even released.
- In other words – inmates are programmed for failure upon release to the community.
- What Do Inmates Say They Will Do as Soon as They “Hit the Streets”?
- Make some money (legally or otherwise).
- “Sex it up!”
- Get high.
- Anything else is considered “punk stuff.”

## 	It is for these reasons that a brief, visually-oriented, and peer-facilitated intervention has a high potential for acceptability by drug-involved offenders returning to the community.   

## 	 Research Funding:
 HHS Grant U01 DA16230 
National Institute on Drug Abuse

-  HHS Grant U01 DA16230
- National Institute on Drug Abuse