Transitions: Linkages From Jail To Community

TRANSITIONS, a novel jail-release program for People Living with HIV/AIDS (PLWHA), will use
evidence-based interventions and adapt them to create a comprehensive transitional program
in New Haven County, Connecticut. Evidence-based interventions will include, but not be
limited to, enhanced rapid HIV testing within the New Haven Community Correctional Center
(NHCCC, local jail), intensive case management, continuity of buprenorphine treatment from
the jail to the community setting and a novel Money Management (MM) program that is
predicated on contingency management and has been used to reduce recidivism to jail,
homelessness, mental and social instability and improve social functioning. Individuals to
be targeted for rapid HIV testing will be those who enter the facility with substance use
disorder and mental illness. All individuals who are either diagnosed with the enhanced HIV
testing or who self-identify as being HIV+ will be evaluated by the Infectious Diseases
Contact Nurse (IDCN) who will work in collaboration with the Referrals Coordinator (RC).
The IDCN will coordinate the medical care of the detainee within the correctional setting
while the Referrals Coordinator will begin the process of coordinating the care upon release
and work with the Intensive Case Managers in New Haven and Waterbury upon release.

The HIV in Prisons Program and the Community Health Care Van (CHCV) at the Yale University
AIDS Program, in collaboration with the Connecticut Department of Correction and the
Waterbury Hospital Infectious Diseases Clinic, propose to expand the availability of opiate
substitution treatment and to enhance clinical and social services for PLWHA, who are
transitioning from the jail to the community setting in New Haven county. This work builds
on our previous work to enhance HIV testing in prisons and jails, , , to provide
comprehensive HIV services within prisons and jails, , to implement the country's first
buprenorphine treatment program in jails, to establish effective prison-released programs
for sentenced prisoners, to establish buprenorphine treatment programs in mobile outreach
and in HIV clinical care settings in the community, , and to establish adherence programs
for PLWHA in community settings. Each of these programs and milestones have been
evidence-based, rigorously studied and have resulted in replication in many parts of the
country. As part of Transitions, we will develop a model Money Management program that we
have used in community settings to improve health outcomes for socially and medically
marginalized populations and adapt it for a jail-release program. The Transitions program
will incorporate these elements into a combined intervention and will result in a clinical
trial to compare the additional contribution of a money management program. The target
population will include drug users who are either being released from or who have recently
been released from prison or jail. Individuals will be fully assessed by a jail-based
Referrals Coordinator and an intensive case manager (ICM) and a treatment plan organized.
Screening and referral will take place either prior to release from the correctional setting
or after release to the New Haven or Waterbury communities. HIV+ jail inmates who are
returning to New Haven and Waterbury will be eligible for this study. As part of a
randomized controlled trial, a subset of these will be randomized 2:1 to a Money Management
program that will be adapted for our population. Direct services provided by Transitions
will include enhanced rapid HIV testing within the jail setting, continuity of buprenorphine
treatment from the correctional system to the community setting, intensive case management
provided as modified Assertive Community Treatment and provision of a Money Management
service. The strengths of this proposal are the:

- Addressing unmet medical, drug treatment, case management needs in New Haven county -
these are statewide priority areas for PLWHA according to our state needs assessment;

- Collective experience and expertise in the collaboration between the Yale University
HIV in Prisons Program, the CHCV, the Connecticut Department of Correction, the
Waterbury Hospital ID Clinic, and a number of collaborating institutions within New
Haven County;

- Novelty of introducing an approved treatment modality for opiate dependence
(buprenorphine), that to date, has not been fully expanded to meet the needs of PLWHA;

- Novelty of prescribing opiate substitution therapy for released prisoners with DSM-IV
criteria for opioid dependence BEFORE relapse to drug use;

- Novelty that the Connecticut Department of Correction is the first and most
comprehensive system to provide buprenorphine for supervised opiate withdrawal (detox)
for opioid dependent patients, thus allowing for its prescription as part of a relapse
prevention program from prison and/or jail;

- Benefit of having an integrated correctional system that means that the jails and
prisons are one system in Connecticut and thus able to track inmates throughout both
the jail and prison system;

- Novelty of applying an evidence-based Money Manager program to released prisoners, most
of whom have significant problems with substance abuse, mental illness and
homelessness;

- Use of evidence-based interventions, including elements of buprenorphine maintenance
treatment, intensive case management teams and money management strategies to retain
released jail detainees with multiple medical and social co-morbidities.

TRANSITIONS is a novel demonstration program for managing HIV+ clients as they transition
from the jail to the community setting in New Haven County, Connecticut. TRANSITIONS builds
on our previous experience with developing and evaluating novel projects: 1) Project TLC
(Kaiser Family Foundation, Altice, PI), the country's first transitional case management
program for sentenced prisoners; 2) Project BEST (SAMHSA, Altice, PI), the country's first
buprenorphine induction and stabilization program administered through a mobile health care
program; and 3) and Project BELIEVE (HRSA, Altice, PI), one of ten SPNS projects integrating
buprenorphine into HIV clinical care settings. Dr. Altice is also the PI for Project PLUS,
two federally funded studies to develop and test pre-release (CDC, Altice, PI) and
post-release (NIDA, Altice, PI) risk reduction interventions for HIV+ prisoners. The target
population includes HIV+ jail detainees from New Haven County who are either being released
from or who have recently been released from jail. Prison-release programs where sufficient
time to plan for discharge have demonstrated significant success, however guidance for
jail-release programs is urgently needed. This jail population desperately needs integrated
services because of the high prevalence of HIV/AIDS, mental illness and recurrent
homelessness that this incredibly vulnerable population faces as it attempts to reintegrate
into the community.

Central to TRANSITIONS, we propose to develop and integrate effective, evidence-based
interventions that include the following elements: 1) intensive case management (ICM) which
is community-based outreach that employs feature of assertive community treatment; 2) opiate
substitution therapy, primarily in the form of buprenorphine maintenance therapy; 3)
enhanced communication linkages between the jail and the community. Eligible clients will
include those who are HIV+ and who are either pre-release or who were released within the
past 30 days. All eligible patients will receive these core elements. All Transitions
clients will then be randomized 2:1 to receive additional Money Management (MM) services or
no additional services. Money Management services, whose principles are predicated on
contingency management, have been demonstrated to stabilize patients through improved social
functioning, adherence to care, and decreased homelessness and substance misuse among
patients with substance use disorder and severe mental illness.

Inclusion Criteria:

- HIV Seropositive

- 18 years of age or older

- male and female

- incarcerated but not sentenced inmates

- releasing to New Haven area

- releasing to Waterbury area

- within 30 days post release from jail

Exclusion Criteria:

Not meeting inclusion criteria