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Project START+ for People Living with HIV (PLWH):

an HIV/STI/hepatitis linkage to care and risk reduction program for people living with HIV and returning to the community after incarceration

Project START and Project START+ were both developed to improve HIV, STIs and hepatitis prevention and increase linkage to care, post release from incarceration. The model itself is being used around the world for any health condition that requires linkage or continuity of care; examples include chronic conditions (hypertension, diabetes), tuberculosis, substance use and mental health disorders. It can also be used for COVID linkage and continuity of care.

References:

"...research conducted with the original Project START intervention..."

Wolitski, R. and the Project START Writing Group, for the Project START Study Group. Research and Practice: Relative Efficacy of the Multisession Sexual Risk-Reduction Intervention for Young Men Released from Prisons in 4 States. American Journal of Public Health 1854- 1861 Vol 96, No 10; October 2006.

"...this pilot indicated that over 70% of Project START participants living with HIV attended their first medical appointment in the community after release from a correctional facility"

Zack, B., K. Cranston, T. Barker, E. Nettle, D Fukuda, D. Isenberg, L. Levy, A. Montgomery and K. Kramer. Corrections to Community: Piloting Project START to Include HIV-Positive Inmates in Massachusetts Correctional Facilities. Abstract ID: 1093 National HIV Prevention Conference, Atlanta, GA, August, 2009.

 

"...a study compared an eco-systems- based intervention to an intervention based on Project START for people living with HIV "

Grinstead Reznick, O., McCartney, K., Gregorich, S., Zack, B., Feaster, D. An Ecosystem-Based Intervention to Reduce HIV Transmission Risk and Increase Medication Adherence Among Prisoners Being Released to the Community. Journal of Correctional Health Care, 19(3) 178-193, 2013.

"Results from the PS+ adaptation pilot..."

Zack, B. and Kramer, K. From Incarceration to Linkage to Care: Adapting Project START for PLWH. Abstract: 1292. National HIV Prevention Conference, Atlanta, 2015.

Project START & Project START Plus

The Project START+ model is currently being implemented around the world for any health condition that requires linkage to care upon release from prison.

Intervention Overview 

Project START+ (PS+) is an HIV/STI/hepatitis linkage to care and risk reduction program for people living with HIV who are returning to the community after incarceration. The program consists of six one-on-one sessions with each participant, which serve as a “bridge” in their return to the community. Participants begin the program up to two months prior to their release from prison or jail, and continue the program for three months after release.

PS+ is based on research conducted with the original Project START intervention that was tested at eight prisons in four states. Fewer men who participated in the multi-session program (Project START) reported unprotected anal or vaginal sex at six months after release.

 

Utilizing Project START with People Living with HIV (PLWH)

During the translation of Project START from research to community practice, one of the test sites piloted the intervention with people living with HIV (PLWH). Data collected from this pilot indicated that over 70% of Project START participants living with HIV attended their first medical appointment in the community after release from a correctional facility. More recently, a study compared an eco-systems- based intervention to an intervention based on Project START for people living with HIV. Both groups reduced sexual risk behaviors over the 12-month follow-up period, but individuals participating in the eco-systems based intervention were significantly less likely to take their HIV medication or be adherent to their HIV medication regiment than individuals participating in the Project START-based intervention. Individuals in the Project START-based intervention were also significantly less likely to be reincarcerated.

Informal Adaptation

Since its initial national dissemination in 2009, various organizations implementing Project START have enrolled people living with HIV as program participants. Project START is a client-centered program, making it feasible to incorporate the goals and needs of PLWH as an integral part of the program and prioritize “linkage to care and treatment.” Until 2016, implementing organizations had “improvised” their informal adaptation of Project START for PLWH.

Formal Adaptation

From 2014-2015, The Bridging Group (TBG) collected process data on “lessons learned” and client-level outcome data from sites that had locally adapted Project START for PLWH. TBG utilized this information to inform the development of new, formally adapted Project START+ (PS+) materials. These formally adapted materials were piloted at two organizations currently implementing Project START for PLWH.

Results from the PS+ adaptation pilot demonstrated that of the 28 PS+ participants at the two sites, 100% received their supply of medications upon release from custody, 75% received a prescription for their medication, 93% filled their prescriptions in the community, and 96% were linked to HIV care in the community after release. At one site, 100% were reenrolled (or reinstated) into the AIDS Drug Assistance Program (ADAP), 58% enrolled in Medicaid and 53% enrolled in insurance.

Based on results and input from the PS+ pilot sites, the formally adapted PS+ materials were finalized and the first training of facilitators with the adapted PS+ materials was conducted in January 2016.

PS+ Intervention Overview

The two PS+ pre-release sessions focus on 1) post-release linkage to care; 2) reentry needs; 3) individualized risk behaviors; and 4) risk of reincarceration. More specifically, these sessions incorporate information and activities, including:

  1. Complete linkage to care, behavioral risk and reentry needs assessments;

  2. Utilize a strengths-based approach to develop individualized linkage to care goal sheets, behavioral risk reduction goal sheets, and other reentry needs goal sheets as appropriate;

  3. Confirm, enroll or provide linkage to Medicaid or Health Insurance and AIDS Drug Assistance Program (ADAP) enrollment and complete necessary forms and applications, including Health Insurance Portability and Accountability Act (HIPAA) release forms;

  4. Obtain participant’s medical file (or arrange to obtain information upon release);

  5. Identify participant’s HIV medications and/or prescription given at time of release (or support the participant to obtain medications at time of release);

  6. Support an individuals’ broader reentry needs with facilitated referrals to social service providers and other treatment needs (housing, substance use treatment, mental health care, income and employment, recidivism prevention, etc.);

  7. Schedule post-release follow-up session.

 

The four PS+ post-release sessions incorporate information and activities, including:

  1. Ideally, meet with the participant within 48 hours of release at their community medical provider’s location;

  2. Assure medications are obtained by the participant in the community;

  3. Provide ongoing facilitated referrals for other treatment and social service needs;

  4. Review and update linkage to care goal sheets, behavioral risk reduction goal sheets and other reentry needs goal sheets including recidivism reduction as appropriate;

  5. Provide risk reduction materials and information (e.g., condoms, syringe cleaning supplies, syringe exchange referrals, etc.) as needed;

  6. Provide additional “other sessions” as needed (e.g., crisis management, extended sentence, etc.)

  7. Engage participant in longer-term system of care, medical home and other support.

If you are interested in scheduling a training or receiving Technical Assistance to implement Project START or Project START+ in your community, please contact us for more information.