The primary purpose of this Correctional Demonstration Project (CDP) is to improve the health and overall quality of life of jailed inmates about to be released to the community. Targeting HIV+ substance abusing men of the metro Atlanta area, starting November 2007, this program will strategically provide comprehensive healthcare, enhanced case management, substance abuse treatment and prevention education relative to HIV/AIDS and STDs. An assessment of need revealed that HIV disproportionately affects inmates; inmates are more than likely to be substance abusers, negatively impacting health outcomes; and there is not a sufficient amount of services to meet the health needs nor the substance abuse treatment needs of this population.

AID Atlanta proposes to develop and implement a project that will (1) increase the medical treatment adherence rate of HIV+ releasees by immediately linking them to primary care while also providing coordinated services including enhanced case management, inpatient and outpatient substance abuse treatment, housing, and other supportive services; and (2) decrease the rate of inmate recidivism by addressing the underlying factors that cause individuals to be repeat offenders, including treatment of substance abuse, providing intensive support and guidance to assist clients in leading healthier lives and making healthier choices, and providing necessary life coaching, prevention education, self esteem building and empowerment opportunities to affect behavioral change.

Care Alliance proposes to identify HIV-infected individuals in the County and City jails through pre-release testing, counseling and case management; to provide health care services to those already diagnosed with HIV and in the jail system; to ensure linkages to care following release from jail; and to provide support services upon release from the correctional facilities and entrance back into the community.

Care Alliance plans to target inmates that are known to be HIV-positive and test those pre-release inmates who are within the two jails at the Cuyahoga County Corrections Center. The targeted populations include substance abusers, commercial sex workers, and other individuals being held and/or pre-released from County and City jails.

The AIDS Care Group will initiate a Demonstration Model of Innovations in Prisoner Release and will utilize deployed case management, outreach, transportation, food, shelter, phone cards, and clothing to insure for each targeted client appropriate and timely linkages into clinical care and social services; seamless reintegration into the community; adherence to HIV medical care; and commitment to risk and harm reduction behaviors. Within 4 months current staff with considerable experience in prison systems, HIV medical care, case management, psychiatry, psychosocial services, and HIV education, counseling and testing will coordinate services with five Pennsylvania county jails to reach prisoners before discharge and to effectively plan for and carry out comprehensive discharge and reintegration activities.

The AIDS Care Group plans to develop an innovative and replicable model of HIV education and services within five Pennsylvania county jails, and make discharge planning and reintegration identifiable and structured programs that address all current barriers to clinical and social services for incarcerated and newly discharged HIV positive adults.

Transitions is a novel demonstration program for managing HIV+ clients as they transition from the jail to the community setting. Rapid HIV testing will be enhanced within this setting to improve diagnostic screening for HIV. The Transitions intervention is based on three evidence-based components that will be adapted for jail-released settings: 1) buprenorphine maintenance therapy (BMT) for opioid dependence; 2) intensive case management (ICM) with elements of assertive community treatment; and 3) money management (MM) that utilizes an assigned payee to manage financial resources to reduce social instability, homelessness, substance abuse and mental illness. A randomized controlled trial of MM will be conducted to determine if this added contribution may lead to previously unattained outcomes.

The proposed project will address primary care and service needs of women who are living with HIV in jail and upon returning to the community, with an emphasis on building effective community linkages specific to the needs of women. The proposed intervention targets incarcerated women in Cook County Jail. To enhance continuity of quality care and services for incarcerated women with HIV, the University of Illinois at Chicago will plan interventions before release, and continue to mitigate barriers to obtaining care and services in their communities.

The Hampden County Correctional Center (HCCC) in Springfield Massachusetts has developed a "public health model of correctional health care" that is recognized as a national model. HCCC promotes continuity of care for inmates and releasees by using dually-based physicians and case managers working at the jail and at community health centers in Hampden County. The model emphasizes five elements: early detection, effective treatment, education, prevention, and continuity of care. The proposed project will enhance current linkages in primary care and social support services by adding dually-based mental health clinicians that will provide mental health assessment and treatment services in the jail and at the collaborating community health centers that include the Holyoke Health Center, the Caring Health Center, Mason Square Neighborhood Health Center, High Street Health Center, and Brightwood Health Center. Mental health services will be provided by a contracted, non-profit vendor, Behavioral Health Network. This provider delivers on-site outpatient and inpatient services at the jail of the health services department and through this project will expand services to increase continuity care through follow-up services at community health center sites that provide primary care to HIV-infected releasees. The mental health services staff includes psychiatrists, social workers, clinicians, administrators, and program managers. The project will also increase the capacity of the collaborating health centers to provide medication-assisted treatment for opioid addiction within the HIV primary care and support service network. Additional focus of the project will be to serve those HIV-infected individuals with co-occurring disorders, posttraumatic stress disorder, and HIV-infected women inmates and releasees.

The South Carolina Linkage Program for Inmates (SCLPI) is designed to address the core goals of identifying HIV-infected individuals in jails and promoting their participation in HIV primary care and other support services as they re-enter the community. To do so we will implement rapid testing and a brief linkage coordination intervention that has been demonstrated in clinical trials to be effective in improving linkage with HIV primary care and substance abuse treatment. We will also implement a brief educational program that will be provided to inmates immediately following their detention in the Alvin S. Glenn Detention Center (ASGDC).
The ASGDC serves as the intake center for un-sentenced misdemeanor and/or felony detainees/inmates and as an incarceration facility for sentenced offenders.

Philadelphia FIGHT, in partnership with Action AIDS and the Center for Mental Health Policy and Services Research at the University of Pennsylvania, proposes to increase capacity and enhance coordination of services for people living with HIV/AIDS within the Philadelphia Prison System and once released through a Healthcare Linkage Program. The program will offer five core services: 1) in-reach within the nine local jails; 2) ex-offender case management services initiated in the jails and continued at Action AIDS; 3) in-jail discharge planning; 4) an ex-offender HIV primary care clinic at the Jonathan Lax Center; 5) a 5 week patient education program housed at FIGHT. All services will be coordinated through weekly partner case conferences, informed by a multi-agency task force, and refined and disseminated through data collection and evaluation results.

NYC Department of Health and Mental Hygiene (DOHMH)

Special Projects of National Significance (SPNS) Planned Reintegration Opportunities to Gain Release & Access Medical care

DOHMH has established a Continuum of Care model for persons living with HIV/AIDS in city jails that includes testing, treatment and discharge planning. DOHMH, in collaboration with Rikers Island Transitional Consortium (RITC), proposes the SPNS Program as an enhancement to the existing HIV Continuum of Care. This program will provide for the unmet primary care and substance abuse needs of people living with HIV/AIDS by providing linkages to care for people released from city jails within 7 days or to Alternative to Incarceration (ATI) programs for those potentially facing sentences longer than one year. The SPNS program will include identification of clients, assessment of need, discharge plans, and placement in community programs as appropriate, with follow-up to ensure ongoing participation in community health care and services.

The overarching goal of this demonstration project is to enhance existing HIV counseling and testing services in the jail setting, and augment linkage to health care for HIV-positive persons in Southeastern New England transitioning to the community after release from jail. This will encompass linkage to HIV primary care, as well as mental health and substance abuse treatment, dentistry, and ophthalmology.