For more than a decade, proper care for HIV-positive offenders meant getting them on the right medications. But as the idea of re-entry has blossomed in corrections, agencies have realized that proper care means a holistic approach to offenders' needs.

Now, adequate health care includes treatment inside the walls as well as discharge planning for outside that encompasses locating shelter, finding employment, counseling and connections to medical care in the community.

"People are repeating cycles of behavior and it is costly," said Sheriff Andrea Cabral of Suffolk County, Mass. at the recent HIV in Corrections conference hosted by the AIDS Action Committee of Massachusetts. "The cost for medical care for each inmate is astounding and we haven't even begun to measure the cost in the community, depending on how they act out."

Cabral told participants at the conference that corrections and elected officials need to realize the negative impact that this population can have on public health, the community and on the criminal justice system if they continue to repeat risky behaviors, commit crimes and are not supported in the community after release.

"We need to have a shift in mindset," she said. "Corrections people and elected officials need to recognize there is an obligation to the community to deliver people back better that they were when we got them."

In Suffolk County, where offenders are either held short-term at the Nashua Street Jail or sentenced to the Suffolk County House of Correction, programs for HIV-positive offenders have expanded. In the House of Correction, both offenders and staff receive education about HIV, and inmates receive counseling, transitional planning and referrals as they near release. Services have also expanded in the jail, which traditionally is a more difficult setting to reach sick offenders to help them change their behavior.

According to Tony Domagala, Suffolk County's Health Care Services Administrator, one of the biggest problems recently is that diagnosis of AIDS has increased.

"That means people are not being compliant with their medications and are going back to the same risky behaviors," he said.

With transitional programming at the jail, inmates who are known to be at risk, such as sex workers or intravenous drug users, are targeted specifically for testing and counseling. Once they make contact in the jail, they are eligible for transitional services such as housing and drug assistance.

With these efforts to work from the inside out, Suffolk County hopes to continue to improve outcomes for these offenders on the outside.

In addition, some long-standing community advocacy programs have implemented new approaches to serving HIV-positive offenders and enhance their chances for success.

Advocating on the Outside

While many offender advocacy programs were originally formed to assist offenders after release, in recent years they have been able to connect with HIV-positive offenders prior to discharge by utilizing targeted funding sources. The result has meant a real improvement in outcomes for this population once it arrives in the community.

The Fortune Society, located in New York City, has advocated for ex-offenders since 1967. With the goal of helping this group succeed in the community, the Fortune Society employs 200 staff, two-thirds of which are ex-offenders, to guide them to eventually care for themselves.

"The way people learn is by seeing people they can identify with. As some get their feet under them, they can reach back and help others. We know they learn best by watching," said The Fortune Society's Executive Director JoAnne Page.

According to Page, under this premise, the organization has continued to expand its services as the needs of the population expand to include substance abuse treatment, peer education, connections to medical services, career development and other services.

One immediate way The Fortune Society begins to lend a helping hand is through its drop-in center, which is located where New York City ex-offenders are dropped off by bus after release. The drop-off, at Queensboro Plaza, is full of temptations to return to the offenders' old ways of living, and the drop-in center provides them with another option, Page said.

"The idea of intervening immediately to increase the odds [of success] is important," Page said.

Once the offenders begin to learn about the services available from The Fortune Society, Page said the staff does all it can to keep them.

"What we've learned is when people come to us, they've come a long way to get there. If you send them elsewhere, you might lose them," she said at the recent HIV in Corrections conference.

That is how the organization came to assist ex-offenders with HIV. According to Page, in the late 80s and early 90s the ex-inmates asking for help either had HIV or knew someone who did.

With the assistance of federal Ryan White Care Act funds, The Fortune Society was able to create a case management model that involved counseling on the inside as well as services on the outside.

In recent years, The Fortune Society has expanded its services again to help offender specifically with the difficulties they face in funding transitional housing.

"We found if they didn't have a safe place to live, they wouldn't succeed," Page said.

The opening of The Fortune Academy in 2002 was a direct response to the housing problems ex-offenders were having.

The academy helps create a seamless transition from incarceration to success on the outside by offering temporary emergency housing and long-term housing as well as a central location for the provision of other services this population needs.

According to Page, the academy is considered "low threshold" in terms of the criteria ex-offenders must meet to receive services. Offenders need no clean time prior to coming to the academy, but are expected to stop drug use once they enter, to work, and enter into treatment if they need it.

Page said peer advocates live with the offenders in the house and support them and push them along towards success in the community. She believes that it is the peer model that makes all the difference.

Lyn Levy, Executive Director of SPAN Inc. a non-profit offender advocacy organization in Massachusetts, agrees with Page's assessment.

"People in prison with HIV are stigmatized, but they feel a lot of support from their peers," she said.

Levy said that inside correctional institutions inmates tell other inmates how to survive with HIV.

"They can't do needle exchange or distribute condoms, but they have word of mouth and [teach each other] how to clean needles and have safe sex. Inmates take care of each other," she said.

But when they are discharged, these offenders lose this support network and that is when they can get into trouble - both health wise and with temptations to return to former ways of living.

This is where SPAN comes in to fill that void.

At SPAN, much like The Fortune Society, the group works with offenders and ex-offenders to provide health education, education, release planning, substance abuse counseling, case management for reintegration as well as transitional housing and resource centers in the community.

Most recently, SPAN received a grant from the Substance Abuse and Mental Services Health Administration to partner with the Suffolk County, Mass., House of Correction to help offenders ages 18 to 24 re-integrate into society.

As a part of that grant, Levy said, the targeted group will receive services to treat substance abuse as well as job development and job training assistance. She said the grant is designed to target a large number of offenders who are incarcerated, yet haven't traditionally received attention and services in the community once they are released.

But the challenges in assisting offenders are multiple.  In addition to health care issues that HIV-positive offenders face, some also come back into the community with co-occurring issues, including mental health problems.

Addressing Mental Health Complications

At the Lemuel Shattuck Hospital in Boston, a special integration program has been developed to assist offenders with multiple issues, from mental health care to HIV care.

Led by Dr. Carl Fulwiler, the program provides psychiatric counseling, review of medications, substance abuse evaluations and referrals.

He said he is not surprised that people involved with the criminal justice system have so many compounded problems and need so much more assistance in the community.

"People with mental illness are more likely to be sentenced for the same crime, incarcerated longer for crimes and disciplined for infractions," he said.

And, if offenders with mental illness have major health problems such as HIV, then their needs are magnified.

Sean Harding of SPAN Inc. in Massachusetts also sees this population as one in dire need of assistance on multiple levels.

Harding told attendees at the HIV in Corrections conference that not only do HIV-positive offenders have health issues such as fatigue, but they also may experience depression, loneliness and, in terms of re-entry, may need housing, a job and be tempted to use drugs again.

Clinics such as Fulwiler's and programs through SPAN help address offenders' needs once after release to give them a fighting chance to succeed.

"It's inevitable they will be at great risk to go back to prison. Our goal is to break this cycle," Harding said.

Harding said the goal for transition programs is to minimize relapse and promote a stable life for these offenders. That means they must address the risk for relapse early on within the first six months of release, but also the risk for relapse after their lives have become stable.

In the first six months the needs are immediate, they need medication and a roof over their heads. But the needs change after those goals are accomplished.

Harding explained that offenders post release can be so focused on meeting all their needs - medications, housing, work - that they don't have time to consider where their life has taken them. After they have become stabilized, reality tends to set in.

"Once things become stable, new risks arise that are social and existential. They [consider] their mortality, they may feel no meaning in life. Those who are successful find a new identity in society," Harding said.

Therefore, many in the community and in corrections have begun to realize that it is their joint responsibility to provide as much support as possible to this population to end their cycles of destructive behavior and give them a new perspective on life.

 "When you look at prisons in the context of the community at large. It's a dumping ground. It's the failed treatment center, the failed community health network, it's people who haven't been able to get through a difficult system," said Levy.

But with a supportive approach from both the criminal justice system and agencies in the community, these offenders may finally experience success.

Resources:

SPAN Inc. - 617-423-2717

The Fortune Society - www.fortunesociety.org

Shattuck Hospital - 617-522-8110

Coming Home, A Resource Directors for Ex-Offenders http://www.exoffenderresources.org