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OCTOBER & NOVEMBER 2007
Spotlight II:
The BRIGHT Project: Bridges to Good Health and Treatment for HIV-Infected Individuals Being Released from Prison
David Alain Wohl, MD Associate Professor of Medicine Division of Infectious Diseases AIDS Clinical Research Unit The University of North Carolina- Chapel Hill Disclosures:Speaker: Abbott Laboraties, Gilead Sciences, Inc., Tibotec Therapeutics, Roche Pharmaceuticals, Merck & Co., Boehringer-Ingelheim, Bristol-Myers Sqibb. Introduction The Bridges to Good Health and Treatment (BRIGHT) Project began as a National Institutes of Health (NIH)-supported clinical trial that aimed to understand if an intensive case management intervention that began within the three months prior to state prison release and continued for six months post- release could increase access to HIV care and services, and reduce recidivism and enhance safe sex practices among HIV-infected releasees in North Carolina. The trial began in 2001 and enrolled 104 individuals who were randomized to the intervention or to standard discharge planning, which does not include post-release activity. Preliminary results indicate the intervention is successful at increasing access to routine HIV care and reducing risk of re-arrest. Based on these findings, the BRIGHT intervention has now been made a non-research service offered to the majority of HIV-infected inmates facing release. Program Overview The BRIGHT Program is a unique intervention designed to improve the well-being of HIV-infected prison releasees. The case management approach used in the program is based on the Strengths Model. This model holds that all individuals have strengths, desires, aspirations, interests, experience talents, knowledge, resiliency and ascribed meaning. It is these that are the focus of a healthy helping relationship, and not the concentration on weaknesses or deficits. The work is done with participants within the context of a collaborative and mutually enriching and respectful partnership in order to identify, secure and sustain a range or resources (both external and internal) needed to live in a normally interdependent manner in the community. Unlike traditional case management, the Strengths Model permits the participant to be an active part of the decision-making process rather than be passive or dependent on others. The BRIGHT case managers begin to work with participants as soon as three months prior to scheduled release, meeting with them regularly to assess for strengths and developing a personal wellness plan together. After release, the BRIGHT case manager will work intensively along side the participant to realize the plans established during incarceration, refining them as needed to confront new goals and challenges. After six months, the participant is slowly transitioned to community case management services. BRIGHT case managers are permitted a maximum case load of 15 participants as a heavier case load would compromise the quality of the intervention. All HIV-infected inmates in North Carolina, including the BRIGHT Program participants, also receive discharge planning assistance during their incarceration from North Carolina Department of Corrections (NCDOC) HIV Outreach Nurses. These nurses and the BRIGHT case managers work closely especially as release nears. Accomplishments to Date The program began as a clinical trial of 104 inmates. Preliminary results following the release of the first 91 participants have been previously presented at the 2006 International AIDS Society Conference in Toronto. At the time of the analysis, 81% of the participants were African-American, 26% were women, median CD4 cell count was 350/mm3 and median viral load was 1,430 copies/mL; and 74% were taking antiretroviral medications. Ninety percent had a history of substance abuse and at baseline, 51% had major depression based on standardized screening assessment with the CES-D. At three months post-release, only 21% of those receiving bridging case management had not attended a routine HIV clinic visit compared to 43% of those not receiving the intervention (p=0.059). Similarly, emergency room visits, a measure of inadequate access to routine medical care, occurred in 28% of those assigned to the case management versus 44% of the controls. Re-arrest rates for those under case management are generally half that of the controls. Final analyses of the complete cohort are ongoing as the final on-study visit occurred in September 2007. All participants are followed for a year post release. Following the early success of this trial, the investigative team sought and received funding from private foundations to continue the program and expand access to the intervention. During the trial three bridging case managers were employed and worked with participants returning to the three largest metropolitan areas of North Carolina (Raleigh-Durham, Greensboro-Winston-Salem, Charlotte). With the expansion of the program, BRIGHT is now in almost 30 counties statewide, including Asheville in the western part of the state and rural areas well outside of urban centers. Over 45 participants have now been enrolled in the post-study program since February 2007 and six case managers are administering the BRIGHT intervention. Future Steps While the BRIGHT program continues through the generosity of private funding sources, other support will eventually need to be identified to maintain the program. Following the final analysis of the trial results, support from governmental and other sustainable sources will be sought. Meanwhile, the program has established strong collaborations with community AIDS Service Organizations, training case managers within these organizations in Strengths Model based bridging case management. In a unique arrangement the BRIGHT Program clinically supervises these community case mangers. The benefits of this program have been evident to the staff and participants, as well as community service providers. During the next year, we will disseminate our instruments, manuals and procedures so that others can also develop and implement transitional programs to identify and capitalize on the strengths of HIV-infected releasees.
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