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Prisoner HIV program leads to continuum of medical care after release

May 08, 2008

By linking HIV positive prisoners to community-based medical care prior to release through an innovative program called Project Bridge, 95 percent of ex-offenders were retained in health care for a year after being released from incarceration, according to researchers from The Miriam Hospital. Continuity of medical care can reduce costs to the criminal justice systems, improve health outcomes, and may reduce HIV transmission.

The complete study reviewing the effectiveness of Project Bridge, a program developed by The Miriam Hospital in Providence, R.I., is published in the May 2008 issue of the Journal of Health Care for the Poor and Underserved.

"By taking a multidisciplinary approach involving medical providers, social workers, and outreach staff, Project Bridge has demonstrated that the complex needs of HIV positive ex-offenders can be addressed to increase social stability and improve health care retention," says lead author Nick Zaller, Ph.D., of The Miriam Hospital and The Warren Alpert Medical School at Brown University.

The benefits of the program are far-reaching as ex-offenders engaged in medical care are more likely to achieve social stabilization and less likely to return to prison.

"Ex-offenders are often released to impoverished communities from which they came - the potential this environment offers for relapse into drug use and lack of access to health care poses a threat to the health benefits they may have gained during incarceration," says principal investigator Leah Holmes, M.S.W., project director of Project Bridge and an adjunct professor at the University of Connecticut School of Social Work. "Ultimately, this can impose a burden on tax payers who end up paying for re-incarceration and/or emergency room visits for those not taking their medications."

Project Bridge, which was formed at The Miriam Hospital in 1997, engages HIV positive inmates while they are still in prison. Social workers meet with prospective clients within 90 days of their release date to formulate a discharge plan and provide the ex-offender with 18 months of intensive case management after prison release. In addition to encouraging the continuum of medical care, Project Bridge links participants with community resources that help them find housing, employment, transportation, and other social services.

This particular study focused on a total of 59 participants who were enrolled in Project Bridge during the reporting period, May 2003 to December 2005. At baseline:

* 86 percent reported living in unstable housing (e.g. - on the streets, in shelters, in abandoned building)

* 97 percent reported a history of substance abuse and/or binge drinking

* 50 percent reported needing addiction treatment

* 34 percent reported being on psychiatric medication

Researchers found that despite high levels of addiction and mental health disorders, 95 percent of the participants in the program were retained in medical care throughout the 18 months. Furthermore, 46 percents secured housing, 71 percent were linked to mental health care, and 51 percent were linked to addiction services.

"Ninety-five percent adherence rate is excellent for any population, but considering the complex needs of HIV positive ex-offenders, this is quite remarkable," says Zaller.

Project Bridge began in 1996 when The Miriam Hospital applied for a "Special Projects of National Significance" (SPNS) grant, which is part of the Ryan White Care Act. In conjunction with the HIV specialty care within the prison that Miriam Hospital physicians were already providing, Holmes launched the program in 1997 with the primary goal of retaining HIV positive ex-offenders in medical care through social stabilization.

Holmes credits the use of professional social workers with making a difference when it comes to the program's effectiveness, in addition to the length of enrollment, intensity of the program, and collaboration between staff. She points out that untrained people doing the job for the same length of time are unlikely to have the same outcomes.

"Most programs follow clients for six months at the most," she notes. "Also, we found that regular contact is critical in building the relationships between project staff and participants. Many participants have a long history of distrust of the legal system and of treatment providers. Through regular and in-depth contacts, they become more open in expressing their needs and more amenable to allowing staff to work with them."

"Building trusting relationships with this population is an important step in establishing a client-centered approach that allows participants to be full partners in their treatment, recovery, and access to social services," Holmes adds.

The authors note that despite the success of Project Bridge, substantial barriers remain in providing ex-offenders social services upon release.

"In order to break the cycle of addiction, health risks - including HIV infection, criminal behavior, and re-incarceration - we need to implement policies which eliminate our reliance on the criminal justice system to deal with individuals our society has chosen to cast aside: those who suffer from addiction, mental illness and/or HIV," says Zaller.

"We must move towards a more compassionate and just society where we engage those who suffer from the diseases of addiction and mental illness rather than lock them up and hope they just go away," he adds.

Lifespan