HIV Risk and Interest in Preexposure Prophylaxis in Justice-Involved Persons.

Preexposure prophylaxis (PrEP) is underused in persons who use drugs and justice-involved persons. In an ongoing randomized controlled trial in 4 US locations comparing patient navigation versus mobile health unit on time to initiation of HIV medication or PrEP for justice-involved persons who use stimulants or opioids and who are at risk for or living with HIV, we assessed HIV risk factors, perceived HIV risk, and interest in PrEP. Participants without HIV (n = 195) were 77% men, 65% White, 23% Black, and 26% Hispanic; 73% reported a recent history of condomless sex, mainly with partners of unknown HIV status. Of 34% (67/195) reporting injection drug use, 43% reported sharing equipment. Despite risk factors, many persons reported their risk for acquiring HIV as low (47%) or no (43%) risk, although 51/93 (55%) with PrEP indications reported interest in PrEP. Justice-involved persons who use drugs underestimated their HIV risk and might benefit from increased PrEP education efforts.

Decision-Making Styles as a Moderator on the Efficacy of the StaySafe Tablet Intervention.

Background: People with substance use disorders often differ in their decision-making styles. The present study addressed the impact of two decision-making styles (rational and dependent) on outcomes from a StaySafe tablet computer app intervention designed to improve decision-making around health risk behaviors and previously found to be effective for justice-involved people receiving treatment for a substance use disorder and under community supervision. Objectives: Participants were justice-involved residents in residential treatment. After completing a baseline survey, participants were randomly assigned to either complete the StaySafe app or to a standard procedure condition; and then asked to complete a post-intervention survey three months after baseline (this protocol has been registered with clinicaltrials.gov NCT02777086): 348 participants completed a baseline survey and 238 completed the post-test survey. Outcomes included measures of confidence and motivation around HIV knowledge and risks and getting tested. Multilevel analyses addressed the hypothesis that outcomes were related to decision-making style. Multiple imputation (MI) was used to address the effects of missing data. Results: StaySafe was more effective for those in the lower half of the decision-making dependent scale for HIV risks (HIV-Knowledge, Hepatitis testing, HIV Services testing, and Sex Risk, as well as motivation for treatment. The decision-making rational scale was less consistently related to HIV risk. Conclusions: The present study showed individuals with substance use disorders who differed in their decision-making styles reacted differently to the StaySafe intervention. Two scales, rational decision making, and dependent decision making are relevant to consider with respect to interventions targeting improving decision making among drug users.

Study protocol of a randomized controlled trial comparing two linkage models for HIV prevention and treatment in justice-involved persons.

BACKGROUND: Persons involved in the justice system are at high risk for HIV and drug overdose upon release to the community. This manuscript describes a randomized controlled trial of two evidence-based linkage interventions for provision of HIV prevention and treatment and substance use disorder (SUD) services in four high risk communities to assess which is more effective at addressing these needs upon reentry to the community from the justice system. METHODS: This is a 5-year hybrid type 1 effectiveness-implementation randomized controlled trial that compares two models (Patient Navigation [PN] or Mobile Health Unit [MHU] service delivery) of linking justice-involved individuals to the continuum of community-based HIV and SUD prevention and treatment service cascades of care. A total of 864 justice-involved individuals in four US communities with pre-arrest histories of opioid and/or stimulant use who are living with or at-risk of HIV will be randomized to receive either: (a) PN, wherein patient navigators will link study participants to community-based service providers; or (b) services delivered via an MHU, wherein study participants will be provided integrated HIV prevention/ treatment services and SUD services. The six-month post-release intervention will focus on access to pre-exposure prophylaxis (PrEP) for those without HIV and antiretroviral treatment (ART) for people living with HIV (PLH). Secondary outcomes will examine the continuum of PrEP and HIV care, including: HIV viral load, PrEP/ ART adherence; HIV risk behaviors; HCV testing and linkage to treatment; and sexually transmitted infection incidence and treatment. Additionally, opioid and other substance use disorder diagnoses, prescription, receipt, and retention on medication for opioid use disorder; opioid and stimulant use; and overdose will also be assessed. Primary implementation outcomes include feasibility, acceptability, sustainability, and costs required to implement and sustain the approaches as well as to scale-up in additional communities. DISCUSSION: Results from this project will help inform future methods of delivery of prevention, testing, and treatment of HIV, HCV, substance use disorders (particularly for opioids and stimulants), and sexually transmitted infections for justice-involved individuals in the community. TRIAL REGISTRATION: Clincialtrials.gov NCT05286879 March 18, 2022.

A psychometric reevaluation of the TCU criminal thinking scales (CTS).

In the United States, approximately 9 million people cycle in and out of jail and more than 600,000 people are released from prison each year. Unfortunately, the reentry process includes several barriers people must overcome (e.g., criminal thinking) to achieve adequate psychosocial functioning. As such, valid and reliable assessments that allow correctional staff to monitor clients' progress in treatment and test program effectiveness are paramount to reducing this major public safety concern. The TCU Criminal Thinking Scales (CTS) are a widely used assessment of criminal thinking in correctional settings. This study reevaluated the psychometric properties of the TCU CTS using Item Response Theory. Results showed the TCU CTS had good internal reliability and each scale loaded onto one factor. Item level analysis revealed most items adequately fit the model, generally measuring moderate levels of criminal thinking. Furthermore, several TCU CTS scales were negatively correlated with motivation for treatment and psychosocial functioning.

Recidivism Among Justice-Involved Youth: Findings From JJ-TRIALS.

Recidivism, and the factors related to it, remains a highly significant concern among juvenile justice researchers, practitioners, and policy makers. Recent studies highlight the need to examine multiple measures of recidivism as well as conduct multilevel analyses of this phenomenon. Using data collected in a National Institute on Drug Abuse (NIDA)-funded Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) cooperative agreement, we examined individual- and site-level factors related to 1-year recidivism among probation youth in 20 sites in five states to answer research questions related to how recidivism rates differ across sites and the relationships between individual-level variables and a county-level concentrated disadvantage measure and recidivism. Our findings of large site differences in recidivism rates, and complex relationships between individual and county-level predictors of recidivism, highlight the need for more nuanced, contextually informed, multilevel approaches in studying recidivism among juveniles.

HIV Stigma in Prisons and Jails: Results from a Staff Survey.

With numerous HIV service gaps in prisons and jails, there has been little research on HIV stigma attitudes among correctional staff. Such attitudes may undermine HIV services for inmates at risk of or infected with HIV. This HIV stigma attitudes survey among 218 correctional staff in 32 US facilities (1) provides an overview of staff's stigma attitudes, (2) reports psychometric analyses of domains in Earnshaw and Chaudoir's HIV Stigma Framework (HSF), and (3) explores differences in stigma attitudes among different staff types. Overall, correctional and medical staff expressed non stigmatizing attitudes toward people living with HIV/AIDS, but perceived that stigma and discrimination exist in others. Factor analyses revealed a three factor structure capturing two mechanisms of the HSF (prejudice, discrimination). Few factor score differences were found by staff type or setting. Implications for correctional HIV services and future research on HIV stigma attitudes are discussed.

Effects of an Organizational Linkage Intervention on Inter-Organizational Service Coordination Between Probation/Parole Agencies and Community Treatment Providers.

Weak coordination between community correctional agencies and community-based treatment providers is a major barrier to diffusion of medication-assisted treatment (MAT)--the inclusion of medications (e.g., methadone and buprenorphine) in combination with traditional counseling and behavioral therapies to treat substance use disorders. In a multisite cluster randomized trial, experimental sites (j = 10) received a 3-h MAT training plus a 12-month linkage intervention; control sites (j = 10) received the 3-h training alone. Hierarchical linear models showed that the intervention resulted in significant improvements in perceptions of interagency coordination among treatment providers, but not probation/parole agents. Implications for policy and practice are discussed.

Efficacy of a process improvement intervention on delivery of HIV services to offenders: a multisite trial.

OBJECTIVES: We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision. METHODS: As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service. RESULTS: The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point. CONCLUSIONS: Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments.

Juvenile probation staff perceptions of engaging families in substance use services.

Objectives: Study objectives were to (a) understand juvenile justice staff members' experiences with engaging families in youth substance use services and (b) identify staff-perceived barriers to family engagement across steps of substance use service provision. Background: Lack of family involvement in juvenile justice system substance use (SU) services is a key barrier to successful treatment of justice-involved youth. Method: From June through November 2015, 33 focus groups were conducted at juvenile justice system probation sites across seven states. There were 263 participants, which included juvenile justice probation and behavioral health staff. Results: Strategies to engage families in services were highly variable across the 33 juvenile justice sites. Juvenile justice staff members identified barriers to family engagement in SU services including family discomfort, distrust of juvenile justice staff, lack of family service compliance, difficulties accessing SU services, lack of transportation, insurance and cost barriers, low perceived need for treatment, lack of SU education, and SU treatment stigma. Conclusion and Implications: Barriers to family engagement directly impact the success of SU service provision in juvenile justice settings. Implementation of strategies to engage families of justice-involved youth (e.g., providing tangible, informational, and emotional support to families, and involving families in juvenile justice policy and care decisions) are critical to improving SU outcomes among this vulnerable population.

Impact of implementation interventions to improve substance use service delivery on recidivism among justice-involved youth.

Substance use disorders (SUD) are prevalent among justice-involved youth (JIY) and are a robust predictor of re-offending. Only a fraction of JIY with substance use problems receive treatment. This paper describes the impacts of system-level efforts to improve identification and referral to treatment on recidivism of JIY. A cluster randomized trial involving 20 county juvenile justice agency sites across 5 states was used to implement an organizational intervention (Core vs Enhanced) to juvenile justice staff and community-based treatment providers, working with 18,698 JIY from March 2014 to August 2017. Recidivism rates over four study time periods were examined. Logistic regression was used to predict recidivism as a function of site, need for SUD services, level of supervision, time, organizational intervention, and time x intervention interaction terms. Results indicated that Enhanced sites showed decreased levels of recidivism compared to Core-only sites, where it increased over time. Additionally, need for SU services, level of supervision, and site were significant predictors of reoffending. Findings suggest the potential value of facilitation of juvenile justice agency efforts to increasing identification of and referral to SUD services of JIY in need of such services for reducing further contact with the legal system.

Asociality and engagement in adult offenders in substance abuse treatment.

In therapeutic community models for drug treatment, individual recovery is principally structured around group meetings and positive peer influences. Research shows that asocial group members with resistant behaviors and attitudes are at risk for poor treatment outcomes and have the potential to adversely impact the therapeutic group. To gain a better understanding of the asocial client's role in the larger treatment process, in-prison treatment data were used: (1) to model and confirm a two-factor solution of asociality consistent with the literature, and (2) to examine the relationship between asocial clients and treatment engagement for validation of the two-factor model. Exploratory analysis resulted in a three-factor solution representing behavioral responsivity, cognitive distortion, and social disassociation dimensions. Nested ANOVA (i.e., clients nested within prison programs) demonstrated that asocial levels (low, medium, and high risk) predicted treatment engagement. Furthermore, comparisons among asocial risk levels indicated that high asocial clients reported significantly lower engagement levels when compared with low and medium asocial clients.

Brief Trauma and Mental Health Assessments for Female Offenders in Addiction Treatment.

Increasing numbers of women in prison raise concerns about gender-specific problems and needs severity. Female offenders report higher trauma as well as mental and medical health complications than males, but large inmate populations and limited resources create challenges in administering proper diagnostic screening and assessments. This study focuses on brief instruments that address specialized trauma and health problems, along with related psychosocial functioning. Women from two prison-based treatment programs for substance abuse were assessed (N = 1,397), including one facility for special needs and one for regular female offenders. Results affirmed that admissions to the special needs facility reported more posttraumatic stress symptoms, higher rates of psychological stress and previous hospitalizations, and more health issues than those in the regular treatment facility. Findings supporting use of these short forms and their applications as tools for monitoring needs, progress, and change over time are discussed.

Examining Concurrent Validity and Predictive Utility for the Addiction Severity Index and Texas Christian University (TCU) Short Forms.

Treatment providers need tools which are designed to identify risk, treatment needs, and monitor client engagement. These are essential components in substance abuse treatment for offender populations. This study evaluated a flexible set of 1-page modular assessments known as the TCU Short Forms and compared them with the measures of global domains contained in the Addiction Severity Index (ASI). The sample was based on 540 adult males and females in corrections-based substance abuse treatment services located in Arkansas and Missouri. Results suggest the set of TCU forms and ASI both reliably represent core clinical domains, but TCU Short Forms explained more variance in therapeutic engagement criteria measured during treatment. Similarities and differences of the assessment tools are discussed, along with applications.

StaySafe: A self-administered android tablet application for helping individuals on probation make better decisions pertaining to health risk behaviors.

This paper describes the development and protocol for feasibility and efficacy testing of a risk reduction intervention designed to improve behavioral health outcomes among drug offenders on probation under community supervision or in residential substance abuse treatment centers. StaySafe is a self-administered tablet-based intervention for teaching better decision-making skills regarding health risk behaviors, especially those involving HIV risks. We are using pre/post, experimental/control group randomized clinical trial (RCT) in both community and residential probation settings with goals to 1) assess the feasibility and acceptance of StaySafe by examining participation rates and satisfaction measures, and 2) examine the impact of StaySafe on decision-making skills, confidence and motivation to avoid sex and drug risks, willingness to discuss health risks and concerns with helpful others, and engagement in health risk behaviors. StaySafe consists of 12 brief sessions and utilizes an evidence-based decision-making schema, called WORKIT, which guides participants through steps for identifying the problem and options, evaluating the options and making a decision about which option to carry out. Multiple sessions of StaySafe provide a practice effect so that the WORKIT steps become easily accessible to participants when making decisions. Three of the sessions provide participants a choice of activities designed to provide additional information about HIV and reinforce lessons learned during the WORKIT sessions. Preliminary data demonstrate feasibility and high levels of satisfaction with StaySafe.

Preparing for analysis: a practical guide for a critical step for procedural rigor in large-scale multisite qualitative research studies.

Despite attention to technical aspects of conducting qualitative research, few studies describe procedures for managing pre-analysis activities in large-scale multisite qualitative projects. As part of the data collection for the Criminal Justice Drug Abuse Treatment Studies, a national multisite research cooperative with nine research centers (RCs) conducted 700 semi-structured interviews to evaluate interorganizational strategies in three protocols focused on improving addiction- and health related service delivery in criminal justice settings. Guided by the research cooperative, RCs collaborated on many aspects of the qualitative data activities (e.g., codebook development and coding activities), however, pre-analysis procedures, such as organizing and managing resources, were primarily managed at the RC level. The present study examines these various practices and describes two exemplary approaches to pre-analysis, with emphasis on lessons learned and recommendations for coordinating resources, managing data, and maintaining fidelity to the study procedures for large-scale qualitative projects.

Evaluating Fidelity to a Modified NIATx Process Improvement Strategy for Improving HIV Services in Correctional Facilities.

In a study aimed at improving the quality of HIV services for inmates, an organizational process improvement strategy using change teams was tested in 14 correctional facilities in 8 US states and Puerto Rico. Data to examine fidelity to the process improvement strategy consisted of quantitative ratings of the structural and process components of the strategy and qualitative notes that explicate challenges in maintaining fidelity to the strategy. Fidelity challenges included (1) lack of communication and leadership within change teams, (2) instability in team membership, and (3) issues with data utilization in decision-making to implement improvements to services delivery.

Understanding the sustainability of implementing HIV services in criminal justice settings.

BACKGROUND: In the growing field of implementation science, sustainability is a critical component of the implementation process of moving evidence-based treatments to regular practice. This paper is intended to extend our understanding of factors that influence the sustainability of HIV services in correctional settings following an organization-level intervention designed to implement improvements in preventing, detecting, or treating HIV for persons under correctional supervision. METHODS: Using semi-structured interviews to elicit perceptions from the principal researcher and executive sponsor at each of nine participating sites, this study explores the variations in the sustainability of HIV services in these criminal justice settings following the experimental implementation intervention. RESULTS: In six of the nine sites, changes in HIV services implemented as a result of the organizational intervention were sustained six to nine months following the end of project implementation. Organizational endorsement at multiple levels is likely the principal factor that facilitates sustainability. CONCLUSIONS: The factors that result in the sustainability of changes to health services in correctional organizations include elements internal and external to the organization. Implementation strategies, such as the change team model strategy used in this study, are also sustainable and can be used to identify other changes that could be made, or improve other aspects of service delivery.

Effect of an organizational linkage intervention on staff perceptions of medication-assisted treatment and referral intentions in community corrections.

INTRODUCTION: Medication-assisted treatment (MAT) is effective for alcohol and opioid use disorders but it is stigmatized and underutilized in criminal justice settings. METHODS: This study cluster-randomized 20 community corrections sites to determine whether an experimental implementation strategy of training and an organizational linkage intervention improved staff perceptions of MAT and referral intentions more than training alone. The 3-hour training was designed to address deficits in knowledge, perceptions and referral information, and the organizational linkage intervention brought together community corrections and addiction treatment agencies in an interagency strategic planning and implementation process over 12 months. RESULTS: Although training alone was associated with increases in familiarity with pharmacotherapy and knowledge of where to refer clients, the experimental intervention produced significantly greater improvements in functional attitudes (e.g. that MAT is helpful to clients) and referral intentions. Corrections staff demonstrated greater improvements in functional perceptions and intent to refer opioid dependent clients for MAT than did treatment staff. CONCLUSION: Knowledge, perceptions and information training plus interorganizational strategic planning intervention is an effective means to change attitudes and intent to refer clients for medication assisted treatment in community corrections settings, especially among corrections staff.

The effect of a local change team intervention on staff attitudes towards HIV service delivery in correctional settings: a randomized trial.

The National Criminal Justice Drug Abuse Treatment Studies research program conducted cluster randomized trials to test an organizational process improvement strategy for implementing evidence-based improvements in HIV services for preventing, detecting, and/or treating HIV for individuals under correctional supervision. Nine research centers conducted cluster randomized trials in which one correctional facility used a modified Network for Improvement of Addiction Treatment (NIATx) change team approach to implementing improved HIV services and the other facility used their own approach to implement the improved HIV services. This paper examines whether the intervention increased the perceived value of HIV services among staff of correctional and community HIV organizations. Baseline and follow-up measures of the perceived acceptability, feasibility, and organizational support for implementing HIV service improvements were collected from correctional, medical, and community HIV treatment staff. Results indicated that the perceived acceptability and feasibility of implementing HIV services improved among staff in the facilities using the modified NIATx change team approach as compared to staff in the comparison facilities.

Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey.

HIV risk is disproportionately high among incarcerated individuals. Corrections agencies have been slow to implement evidence-based guidelines and interventions for HIV prevention, testing, and treatment. The emerging field of implementation science focuses on organizational interventions to facilitate adoption and implementation of evidence-based practices. A survey of correctional agency partners from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) revealed that HIV policies and practices in prevention, detection, and medical care varied widely, with some corrections agencies and facilities closely matching national guidelines and/or implementing evidence-based interventions. Others, principally attributed to limited resources, had numerous gaps in delivery of best HIV service practices. A brief overview is provided of a new CJ-DATS cooperative research protocol, informed by the survey findings, to test an organization-level intervention to reduce HIV service delivery gaps in corrections.