Putting the Pieces Back Together

1. Putting the Pieces Back Together A phenomenological exploration of barriers to HIV care and prevention within a selected cohort of African-American reentrants in the District of Columbia Jerry Brown, Ed.D, MHS District of Columbia Mayor’s Office on Returning Citizen Affairs

2. Terminology • Reentrant • Returning Citizens

3. DCDC • HIV, HCV and mass incarceration target the same communities, leading to a concentration of health disparities w/in correctional facilities • 19,000 transition annually • 4.5% HIV+ • 70% females are sex workers Source: DC Dept. of Corrections, 2012

4. Proportion of Cases Diagnosed in Jail and Living with HIV by Race/Ethnicity and Sex, 2010 Females, N=201 HIV Cases by Race/Ethnicity, N=931 Males, N=730 DC DOH

5. Proportion of HIV Cases Diagnosed in Jail and Living by Sex, District of Columbia, 2010 HIV Cases by Sex, N=931 DC DOH

6. Proportion of Chronic Hepatitis C Cases, by Place of Diagnosis, District of Columbia, 2006-2010 DC DOH

7. Hepatitis C Virus • Estimated 12%to 35% inmates nationwide (state and federal prisons and county jails) have chronic HCV infection • As of 2007, more people die annually of HCV‐related causes than of AIDS, and the gap widens each year, as AIDS-related deaths decline, and HCV-related deaths rise. • Driving factors of the HCV epidemic –incarceration, poverty, and lack of access to health care Bureau of Justice Statistics, April 2008

8. Research Aims • To gather data regarding the lived experiences of reentrants about the social and structural barriers that influence the health trajectories of people with a history of incarceration, drug use, HIV and HCV infection. Groenwald, 2004

9. Conceptual Framework Methodological: • Qual/epidemiology Theoretical: • Social Marginality

10. Rationale for a Phenomenological Approach Husserl, 1938; Van Manen, 1997; Greene, 1997 Phenomenologists are concerned with understanding social phenomena from the perspectives of people involved.

11. Sampling Strategy Purposive Sampling Informed Consent Agreement 10 unstructured in-depth interviews with drug users, including IDUs and MSMs, i.e., “cross-sectional” Pre-screen for criteria Compensated participants Kruger, 1988; Bailey, 1996

12. Participant Characteristics 5 respondents w/ CSOSA 5 respondents unsupervised Avg. time on street 16 months > One year Avg. btw last HIV test 8 Men Ages range: 22-64 Race/Ethnicity: A/A IDUs: 5 Last prison/jail term: Range – 197 days-23 years 3 Women Ages range: 31-43 Race/Ethnicity: A/A IDUs: 1 Last prison/jail term: Range – 228 days-7 years

13. Findings: HIV • “I know of cases where COs (correctional officers) would let other inmates know of my HIV status…for no reason other than to stigmatize me.” • “Some institutions still release people with no meds…or if you are lucky, you may get a three day supply.”

14. Findings: HIV Have you ever declined to be tested for the HIV virus? • “. . . I just don’t want to be bothered…with all the other stuff I got going on, who the hell wants to know they are [HIV] positive. I need someplace to put my kids and housing is just so hard [to find] now. Having a voucher don’t mean nothing, no more. ” • Knowledge of HIV transmission: • “ If she isn’t bleeding, like on her period, I think it’s cool to get down. And, I’m not having oral sex, you know. . . that’s what you got to watch for, having oral sex when she is bleeding.”

15. Findings: Health • How important is your health at this point in your life? • “I guess you can say I lost interest in this [HIV] stuff. I mean, it ain’t like bumping (having sex) with crack heads. The women I deal with got jobs and educations. I need a crib [place to stay] and job and I ain’t having luck getting either one.”

16. Findings: Housing • “The problem with public housing is that managers are doing what they want…just like if you have a record with robbery, they will say you can’t live there. But that’s not the law…only manufacturing of meth or speed can be the reason they can keep you out. Not everybody knows this and they aren’t telling us the real law“

17. Findings: Community • Thoughts on “gentrification” • “Oh, man…they [new residents] have taken over whole blocks. My family is gone; the house is sold. So, my day is just trying to find somewhere to stay, ‘cause the shelter is just like being in the joint [jail]. Those are my choices and testing [HIV] ain’t going to get me a job!”

18. Findings: Socio-economic Vulnerability “I never thought I would have to go through so much for a job. Now, I gotta hustle food stamps. I gotta have some kind of money in my pocket. Everybody doing it; I ain’t never seen so many young dudes on food stamps!! Sell some of my [food] stamps, so I can get a bus pass. How the hell my CSO [supervision officer] think I’m going to get around…they don’t give you anything to help you find a job. Man, this is hard!”

19. Findings: Mental Health • “ You can’t do mental health and tell people you need a job at the same time. Who going to hire, then?”

20. Findings: Substance Abuse • “I don’t have money or a ride (automobile)…and they are moving clinics out of certain neighborhoods. It ain’t hard to see that they are pushing poor [people] out of DC. It’s strange the way they look at you. I mean they are paying a fortune for a house and don’t want to have to look at people coming through their ‘hoods, you know.”

21. Findings: Hepatitis C Virus • “ I’m not shooting up anymore, so that’s not something I’m worried about. (“D”) • “ No concern of mine. You have to be doing a lot of different stuff to get that [HVC}. (“L”) • “ I didn’t want my status known…’cause the C.O.’s will surely tell somebody if you have any sort of virus or sickness.” (“O”) • “People still use [drugs] and do other stuff inside [jails/prisons] and they can’t let people know they positive for anything.” (“M”) • “ You had red dots on your [medical folder] folder to identify your [HCV] status.“ (“O”)

22. Findings: Pains of Imprisonment Deprivations of: • liberty • goods & services • heterosexual relationships • autonomy • security Sijuwade, 2007

23. Side-effects of Incarceration The fatalism of “learned helplessness” (Carlson, 2010; C Dalla et al, 2008) “apathy & oppositional”cultures (Mobley, 2011) “Syndemics” intersecting epidemics ( Singer, 2009)

24. Health Care for Reentrants in The District of Columbia • Driving Forces Restraining Forces Desired State Current State • Employment • Stable Housing • Life Support Coaching • Education/Voc Training • Peer Mentorship • Race and Gender Disparities • Social/Family Network Instability • Socio/Economic Vulnerability • Gentrification • Life/Social Skills

25. Summary of Findings From Interviews Based on these preliminary findings, there are clear suggestions that: • Multiple interaction(s) with the criminal justice system influence post-release health care decisions; nor do respondents make a direct connection between their experiences with corrections, HIV and HCV risk. • Pace of life more chaotic. Primary health care services not a priority in or out of jail/prison • Gentrification may influence the “hierarchy of needs” – housing, employment, transportation – that relegate health care to lower on the list • We face a post-release challenge in identifying HIV and HCV cases and connecting these individuals to wellness interventions

26. The Way Forward Ethnographic / epi approach to track a cross-sectional cohort of reentrants relocating to D.C. metropolitan-area suburbs Improved post-release monitoring and evaluation on HCV Link health-wellness to post-release community- supervision Prisons don’t have enough programs to prepare reentrants for transitioning back to society Diffusion of Innovation, e.g., address the role of gentrification in HIV care initiatives impacting the larger community

27. Thank You!

28. Contact Information Email: yterj1997@yahoo.com