A prison-release program for HIV-positive women successfully links most of those in it with medical care and substance-abuse treatment once they are released from prison. This has resulted in a more than 50-percent decrease in the recidivism rate compared to HIV-positive women released from the prison who are not in the program
Roberta Richman says that when Tim Flanigan visits her correctional facilities each week, his casual manner is the opposite of the prison's hard edge. But Flanigan's style is an accepted part of the correctional atmosphere in Rhode Island because, Richman says, the physician and his colleagues on an HIV-intervention team are respected for going well beyond the call of medical duty.
"Obviously, their program is a vital one for us to have," says Richman, warden of women's facilities in the Rhode Island Department of Corrections. "During the life of the program, we have seen a reduced number of HIV-positive women. This is attributed directly to the team's effort.
"The doctors don't just come, provide care, and go. Their care accompanies the women back into the community when they leave."
Flanigan helps lead the prison-release program for HIV-positive women that successfully links most of those in it with medical care and substance-abuse treatment once they are released from prison. This has resulted in a more than 50-percent decrease in the recidivism rate compared to HIV-positive women released from the prison who are not in the program.
The medical personnel involved in the team are based at Miriam Hospital. The team's faculty members are affiliated with the School of Medicine. Last year, the team described in the American Journal of Public Health how their program could serve as a model for other states to meet the need for community follow-up for HIV-positive women released from prison.
The program may be the first to send academic hospital personnel into public prisons to treat HIV-positive inmates. During its first year, 41 HIV-positive women were released from prison. Among them, 34 followed up with medical care, and 34 of 39 women received aid from either general public assistance or Social Security disability. Twenty-one of 31 women entered into a substance abuse treatment program after release. Of the 14 women who had no place to live, eight were placed in an apartment or group home.
All but two of the women in the program's first year were incarcerated for drug or prostitution charges or both. Thirty-three of the women had been jailed more than twice.
"Success in the program is measured in changed behavior, which is reflected by the reduced recidivism rates," says Kevin Vigilante, M.D., clinical associate professor of medicine, and the program's other leader. "If the women are changing their behaviors by not returning to prison, they may also be reducing the behaviors that lead to drug use and prostitution."
Indeed, women in the prison release program's first year had recidivism rates of 12 percent within six months and 17 percent within 12 months. This compares to 41 randomly selected HIV-positive women at the state prison not in the program who had recidivism rates of 27 percent within six months and 39 percent within one year. Forty-one HIV-negative women who had release dates and charges that matched those of participants in the prison release program had recidivism rates of 22 percent within 6 months and 37 percent within 12 months.
In a presentation this week in Washington, D.C., at the fourth Conference on Retroviruses and Opportunistic Infections, members of the team described how the correctional setting offers a unique opportunity for HIV diagnosis, primary care and links to community resources. Between 1990 and 1994, for example, 34 percent of all HIV-positive persons reported to the Rhode Island Department of Health were diagnosed in prison.
Upon release from prison, HIV-positive women frequently lack primary medical and gynecological care, substance abuse treatment, and psychological and social support. Brown's AIDS program, with the Rhode Island Departments of Health and Corrections, designed the prison release program. It relies on a seven-member team of four doctors, two nurses and a social worker to assist the women.
In the program, team members meet with each woman, three to six months before her release, and up to five times depending on need, to discuss and design after-release plans. This pre-release counseling focuses on medical care, housing, substance abuse treatment and family support. Team members also conduct follow-up on all participants three and six months after release from prison.
"Because of this type of intervention, women begin to trust these medical doctors, particularly when they're told they have a life-threatening disease," Richman says. "Many of the women are scared. But the doctors are gentle, caring individuals. Women who want to trust these doctors and get better will do what they say. The result is that the women receive care that is as good as anybody gets anywhere."
The program also supports a prison-based half-time registered nurse who helps women at high risk for contacting the HIV virus prepare discharge plans that address their housing and job needs, social support and counseling. In fact, the success of the HIV-intervention team has led to the duplication of its services across the state's Adult Correctional Institutions. The program's ability to help women after they leave prison is a key to that success. Compared to men, women typically face shorter prison sentences.
"There is a lot of thinking out loud during the whole transition process leading up to a discharge," Richman says. "This assistance makes a big difference in whether the women come back here." Without discharge-planning assistance, the women may find themselves back on the streets with just their usual survival skills to get them by, she says.
"The first 24 hours after the women are out determines whether they will be back," says Flanigan, an associate professor of medicine. "The program's intervention tries to establish a medical relationship with women in prison and maintain that bond. The doctors who see the women in prison also see them in the community. Each woman's discharge plan is carefully crafted before she leaves prison and is reinforced by the doctor and other team members."
The physicians say that women in the program pattern their lives in abusive relationships. They do not usually engage in self-help activities, rarely trust others, and associate primarily with people who exploit them. Yet the women crave relationships of intimacy.
The women typically leave prison and go right back into the community they came from, Flanigan says. "If we abandon them after prison, disaster awaits them," he says. "And it's a disaster for the community, just in term of the spread of disease."
Vigilante says saving lives saves money.
"There are high personal and societal costs of being HIV positive," Vigilante says. "If the person is also a drug user, the cost to society is astronomical. That makes getting people into treatment very important."
Vigilante has expanded the program beyond the prison. He operates a storefront clinic in South Providence that provides medical care and substance-abuse treatment to HIV-negative women at high risk of contracting the virus.
Moreover, Vigilante and Flanigan run a program that helps children of incarcerated women and substance abusers attend parochial or private schools. Their effort is called RISE, for Rhode Islanders Sponsoring Education. The program recruits mentors for high-risk young people from troubled families to help the young people avoid making the same mistakes as their parents and those around them. The mentors interact with the youngsters and fund part or all of a child's education in a parochial or private school for four or five years through the elementary and middle-school years.
"The work by Tim Flanigan, Kevin Vigilante and others on their team goes well beyond a doctor's call of duty," Richman says. "They are continually looking at community problems and trying to solve them on a small scale."