The purpose of this project is to better understand the post-incarceration needs and resources of HIV+ former prisoners. This population has a poor history of remaining in medical care, resulting in increased viral load, morbidity and disease transmission risk. We have analyzed records of 363 Spectrum case management clients, developed a focus group discussion interview guide and recruitment tools, and received IRB approval to conduct focus groups.

1. Research to Better Engage HIV+
Former Prisoners in HIV Services
Nina Harawa, Ph.D., Associate Professor, CDU College of Medicine
Charles Hilliard, Ph.D., Clinical Director, SPECTRUM Clinic
Pilot funds provided by NIH/NCATS/UCLA CTSI Grant # UL1TR000124

2. Background
• Prisoners are the only group in the U.S. with a constitutional
right to health care.
• This does not guarantee that they will continue to receive
health care upon release—in fact, because of their frequent
unstable status, low health literacy, and competing priorities,
the incarcerated individual’s engagement in medical care often
ends at release -- even when community options for free or
low-cost care exist, as they do for HIV (Baillargeon JG, et al.,
2010; Baillargeon J, et al., 2009).
• A number of studies have shown low levels of entry into and
engagement in care among former HIV+ prisoners.

3. History
• We were partners in a recent effort, funded by AIDS United’s
Access to Care (A2C) initiative, that sought to facilitate linkage
to and retention in care for HIV-positive persons leaving
California prisons.
• Called the Positive Parolee Network (PPN), this project ended
prematurely in March 2012.
• PPN Components
• intensive case management, including reentry support
• peer support, and
• linkage-to-care services.

4. PPN
• During the PPN’s five-month implementation period, we
enrolled 24 people who had been released from prison in the
prior 12 months.
• Although we successfully linked 79% of these clients to HIV
medical care within 30 days, we encountered challenges in
working with them to meet their other case management
goals.
• These issues contributed to frequent recidivism and
inconsistent participation. Mental illness, addiction and
difficulties securing stable, appropriate housing for clients
were major issues.
• Approximately 30% of SPECTRUM’s routine case management
clients report having been incarcerated in the prior 24
months.

5. CERP
• This CERP funded research project allows us to
• continue the momentum of this work,
• build on lessons learned,
• gather data that will allow us to
• improve our intervention for HIV+ former prisoners
• prepare for potential funding opportunities from
AU and others.

6. Research Questions
• What are the most commonly experienced needs and barriers
to medical care among recently incarcerated HIV-positive
former prisoners compared to other clients?
• What are the key differences in background characteristics
between those former prisoners who are and are not retained
in HIV medical care?
• What are the key motivators and other factors that promote
linkage to and retention in HIV medical care among former
prisoners?

7. Methods
Secondary analysis of SPECTRUM data :
• Case Management clients served between 2007 & 2012.
• Compare
• recently incarcerated SPECTRUM clients who were and were not
retained in HIV medical care in the 12 months following their
release from prison.
• retained in care defined as two or more medical visits in a HIV
care setting at least two months apart per measurement year
(HRSA 2008).
• Goal
• assess the key predictors of successful or poor engagement in HIV
care in this group

8. Methods
Qualitative
• Conduct focus groups with HIV positive former prisoners
• four two-hour focus group discussions with
• a total of 20 HIV-positive individuals
• incarcerated in a California state prison within the prior twelve
months
• Form a Community Advisory Board (CAB) and meet with them
3 times to obtain input on:
• the focus group discussion interview guide,
• Interpreting the data
• recruitment,
• service provision

9. Outcomes
• Improve parolee linkage to care: Apply health services
research methods to routinely collected client data in order to
improve ongoing service provision at SPECTRUM. Further, we
intend to use the collected quantitative and qualitative study
data to refine the intervention approach for future grant
applications in order to improve outcomes for HIV+ positive
parolees returning to South Los Angeles (and other
communities across the country).
• Improved utilization of existing client data: Develop a series of
automated reports that SPECTRUM staff will be able to use
going forward to periodically evaluate their client data.

10. CERP Aims Addressed
CERP Aim 1 discusses promoting and sustaining bidirectional
knowledge sharing between community and academia.
• This research project enables SPECTRUM and its staff to work
directly with an academic researcher to apply health services
research methods to analyzing its client data and to gather
and examine additional data on a population it serves but
whose retention-in-care needs have not been fully addressed
by the traditional case management.
• In turn, SPECTRUM and the community advisory board will
share with the researcher the expertise it has gained from
years of serving HIV-positive, low-income individuals,
including many with incarceration histories.

11. CERP Aims Addressed
CERP Aim 2 discusses strengthening community infrastructure
for sustainable partnered research.
• Although SPECTRUM is able to obtain limited, aggregate client
data from preformatted reports provided through the
County’s Casewatch client data system, it lacks the capacity to
look at its data in more detail or over time.
• Through this research, we will identify variables, cross-
tabulations, and trends that would be beneficial for
SPECTRUM to examine on an ongoing basis in order to guide
planning for all of its client populations.
• We will use this information to develop a series of automated
reports and train SPECTRUM staff to periodically recreate
these reports with updated client data.

12. Timeline-deliverables
August 2012 Sept – Oct Nov – Dec January 2013 February
IRB Approval for Obtain IRB approval for Transcribe, review, Review all focus
Quantitative Qualitative Phase and code Focus group transcripts
protocol
quantitative Group #1
data
Draft qualitative CAB Meetings Conduct Focus Final codebook
focus group #2 & 3 Groups 2-4
discussion
interview guide
Preliminary crude Finalize qualitative Develop initial Quantitative date
distributions for focus group code book report
key predictors of discussion guide
interest
CAB Meeting #1 Finalize Transcribe Focus Develop outline
distributions for all Groups 2-4 for one mixed-
predictors of methods
interest manuscript
combining data
from
Conduct Focus Distribute
Group #1 quantitative date
reports

13. Added-value from CTSI
Funding
CTSI funding provides the resources to research an issue that has a
huge impact on the local community, the stability of HIV-positive
former prisoners returning to South Los Angeles and the County at
large. Existing linkage to care services are inadequate and in need of
improved evidence-driven improvements.
• This research has the potential of improving engagement and
retention in HIV care for a very vulnerable population.
• Improved engagement and retention of HIV positive parolees has
the potential of improving parolee health, increasing parolee
stability in the community, reducing further HIV transmissions, and
reducing the need for parolees to access more expensive health care
services and other public resources.

14. Next Steps
 Submit findings (manuscript) for publication.
 Share findings with SPECTRUM clients, DHSP, HIV medical
providers within the prisons and other local provider groups
serving parolees.
 Submit new application(s) for funding for improved case
management services for parolees.
 Ongoing: Utilize data from quantitative analysis to improve
SPECTRUM services to recently incarcerated clients; utilize
data tables for ongoing evaluation of client data.