One of the largest challenges in HIV/AIDS treatment in the current era is that the majority of HIV-infected individuals are not retained in care and therefore not receiving the full benefits of antiretroviral therapy (ART). Health disparities persist, with certain groups at higher risk for poor outcomes, including minorities, youth, substance users and those living in the South. The criminal justice system, where these groups are over- represented, is a critical area of focus to improve HIV outcomes and reduce health disparities. We propose an intervention aimed at improving re-engagement in HIV care after release from jail, which can promote ongoing ART and decrease an individual's HIV viral load, thereby reducing the risk of HIV transmission to others. HIV- infected substance users incarcerated at the Dallas County Jail will be randomized to a community-clinic collaborative intervention versus treatment as usual. Participants randomized to the intervention will undergo a detailed risk and needs assessment from an innovative organization focused on community re-entry after incarceration, called Unlocking DOORS. This organization will provide participants with a personalized re-entry plan, taking into account legal requirements from the court and probation systems, with referrals to an extensive interconnected network of partners and providers in Dallas, including housing, food banks, mental health counseling, substance abuse treatment, job training and transportation. In addition, a formerly- incarcerated community health worker will help the participant navigate needed social and health services, including attending visits at the outpatient HIV clinic, and will function as an integral community extension of the HIV medical team. The primary outcomes of this study will be HIV viral load and substance use at 6 months after randomization, chosen due to its rigor in predicting both individual HIV outcomes and HIV transmission risk. Monitoring of service delivery (referrals made, services utilized, visits with community health worker) and secondary outcomes (re-incarceration, emergency room visits, hospitalizations) will allow for measurement of intervention dose and important related potential impact of the intervention. We will also measure 12-month HIV viral load and retention in care to assess the durability of the intervention. Stakeholders, including HIV clinic patients, HIV community service organizations, and members of the Unlocking DOORS partner/provider network, will be engaged and involved throughout the planning, execution and analysis process of the project. Overall, this multi-sector approach to improving clinical and substance use outcomes in HIV-infected individuals released from jail has the potential to advance the National HIV/AIDS Strategy by improving access to HIV care for an underserved population (substance users involved in the criminal justice system), reducing health disparities and decreasing the risk of HIV transmission. Its unique design with broad community engagement, including collaboration with diversion programs and the court system, also has the potential to also reduce recidivism and build safer communities in Dallas.
This application targets HIV-infected substance users released from jail, a group who is not only at high-risk for developing HIV complications, but who poses a significant risk of HIV transmission to others. The main goal of this proposal is to improve substance use and HIV outcomes and reduce recidivism through community-clinic collaboration. By working with an extensive network of social, legal and medical service providers together with a community health worker, this multi-sector approach has significant implications for public health and public safety.
