Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource Requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Description

Project START is an HIV/sexually transmitted disease (STD)/hepatitis risk-reduction program for people returning to the community after incarceration. The program includes enrollment plus 6 program sessions with each client and works with them one-on-one to serve as a bridge to their return to the community. The program begins up to 60 days before clients are released and continues with clients for 3 months in the community after they are released from the correctional facility.

Project START provides a range of counseling and prevention strategies to tailor the program to the unique strengths and resources of each individual by using a client-centered step-by-step approach. These strategies include goal setting, problem solving, strengthening motivation, decision making, and facilitated referrals. Project START also covers many other issues and challenges people face when they are released from a correctional setting into the community (e.g., finding affordable housing, securing viable employment, or dealing with substance abuse and mental health issues).

Project START has been packaged by CDC’s Diffusion of Effective Behavioral Interventions project, and training and technical assistance is available through the CDC’s Diffusion of Effective Behavioral Interventions project. View information on obtaining the intervention training and materials.

Goals
The main goal of Project START is to reduce HIV, STD, hepatitis risk behaviors in clients after incarceration.

Target Audience
Though the original research targeted young men ages 18 to 29 who were being released from a prison back into the community, the intervention has been expanded to include any person who is being released from a correctional setting back into the community. It can be used with men and women, people of all ages, and for people who are HIV-positive and people who are HIV-negative.

How It Works
Enrollment plus 2 of the Project START program sessions are conducted before release, and 4 program sessions are conducted after release from the correctional setting. During enrollment, participants learn about the program, sign an agreement for services, and complete other enrollment paperwork. In the first program session, program staff and the client review the client’s risk of acquiring or transmitting HIV, STDs, and hepatitis. Then program staff works with the client to develop a post-release risk-reduction plan. In the second program session, the staff and client review the client’s transitional needs. Transitional needs are other life circumstances that may require resources and services to support a client’s successful re-entry into the community. A client’s transitional needs may include housing, employment, or treatment for substance abuse or mental illness. The program staff works with the client to prioritize these needs and develop a plan for meeting them. In the last 4 program sessions, conducted with the client after release, program staff and the client review the client’s needs and goals and update the client’s plans according to his or her life circumstances. In these post-release sessions, condoms are provided to the client. Facilitated referrals connect the client to services in the community.

Theory Behind the Intervention
Project START incorporates strategies involved with prevention case management, motivational enhancement, decision making, and harm reduction. Its goal is to use all of these strategies to help participants develop an individualized risk-reduction plan and lower his or her risk behaviors after release from a correctional facility. For the purposes of this document, we use the term “incremental risk reduction” to represent this theoretical approach.

Incremental risk reduction is a client-centered approach that encourages people to become more aware of their risk behaviors and provides them with tools and resources to reduce their risks. It is personalized and nonjudgmental. It promotes motivation, prioritizing needs, problem solving, goal setting, and other skills the client may need to successfully carry out a plan. The key principles of an incremental risk-reduction framework are the following:

• Covers a wide range of risky to less risky behaviors, with abstinence as a possible option.
• Builds on small successes.
• Deals with the whole person rather than focusing solely on their risk behaviors.
• Follows a flexible approach, with creativity and new ideas that match a person’s overall life situation.
• Understands that working on individual risks starts best by working on the least difficult problems and increasing to more difficult risk situations.
• Supports access to local and community-based services (such as mobile clinics) instead of institutional, formal services (such as hospitals).
• Works with people based on where they are in their lives rather than forcing them to fit into preset goals.
• Recognizes that people need to fully understand the behaviors that put them at risk and receive the tools necessary for change.
• Accepts that people change what they want to change, when they are ready to change, and when their environment allows for that change.
• Understands that the end result may not eliminate all risk but will help to reduce risk.

Incremental Risk Reduction includes strategies that help people identify their current and past risk behaviors and develop individualized step-by-step solutions that will help them reduce their risk behaviors as much as possible.

Research Findings
Overall results of the study showed that participants in the multisession intervention group (Project START) were less likely to have risky sex than were those in the single-session comparison group 6 months after they were released from prison. Risky sex was defined as unprotected vaginal or anal intercourse.

Lessons learned from the Project START study (Grinstead, 2008; Wolitski, 2006) also suggest that HIV, STD, and hepatitis risk-reduction programs for people being released from correctional settings are more effective if they start where the client is and stay client-centered, use small, incremental steps to help clients work on their goals, and integrate HIV/STD/hepatitis risk reduction with a person’s more pressing post-release needs (e.g., housing, employment).

Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory on which the intervention or strategy is based; they are thought to be responsible for the intervention’s effectiveness. Core elements are essential and cannot be ignored, added to, or changed.

Project START has the following 9 core elements:

• Hold program sessions with clients transitioning back to the community from a correctional setting prior to release and continue holding sessions with clients after they are released into the community.
• Use a client-focused, personalized, incremental risk-reduction approach that helps clients develop step-by-step solutions to minimize risk behaviors.
• Use assessment and documentation tools to provide a structured program that includes risk assessment, problem solving and goal setting, strengthening motivation and decision making, and facilitated referrals.
• Staff program with people who are familiar with HIV, STD, and hepatitis prevention activities and with the specific needs of people being released from correctional settings (for example, parole/probation, substance abuse prevention and treatment, homelessness, and mental health issues).
• Staff-client relationships and rapport developed during pre-release sessions must be maintained during post-release sessions to promote client trust and willingness to continue with the program. Thus, the same staff member should conduct both pre-release and post-release sessions with his or her clients. In the case of staff turnover or extended illness, every effort should be made to ensure a smooth staffing transition.
• Conduct enrollment and schedule 2 pre-release program sessions within 60 days of a client’s release. These sessions should focus on the following?
• Giving HIV, STD, and hepatitis information.
• Reviewing a client’s HIV, STD, and hepatitis risk.
• Identifying other transitional needs that may affect a client’s HIV, STD, or hepatitis risk (e.g., housing, employment, or substance abuse issues)
• Working with each client to develop a personalized risk-reduction and transitional plan.
• Making facilitated referrals as needed to community-based support services.
• Schedule 4 post-release sessions. Hold the first as soon as possible, ideally within 48 hours of release. The next 3 sessions should be spaced out over 3 months after release. The post-release sessions should focus on the following:
• Reviewing and updating the risk-reduction/transitional plan developed during pre-release sessions.
• Discussing what hinders and supports clients in moving forward with their risk-reduction/transitional plan.
• Giving them facilitated referrals to needed services by using a detailed resource guide.
• Provide condoms at each post-release session.
• Actively maintain contact with clients, using individual-based outreach and program flexibility to determine the best time and place to meet with them.

Key Characteristics
Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the community based organization  or target population.

Project START has the following key characteristics:

• When conducting sessions inside a correctional facility, do it in the most confidential space available. When conducting sessions in the community, conduct them in a location that is as safe, convenient, accessible, and as confidential for the client as possible.
• All sessions are intended to be held face-to-face. However, sessions can be conducted over the phone if there are special circumstances, for example, if a client has moved out of the service area.
• If clients are re-incarcerated for a short period of time during the post-release period, continue their sessions within the correctional setting whenever possible.
• Schedule additional sessions during the 4- to 5-month time period of the program when a client and staff agree this is useful and possible.
• Give additional resource materials to clients as needed, such as educational materials (brochures on HIV, STDs, and hepatitis) and other useful resources such as hygiene or toiletry kits or phone cards.

Procedures
Procedures are detailed descriptions of some of the elements and characteristics listed above. Procedures for Project START are as follows.

Definition of a correctional setting
Project START must be implemented with people who are incarcerated in a correctional setting and will be released back into the community. Correctional setting refers to any facility that is being administered by a correctional agency. Examples of a correctional setting include prisons, jails, Native American Justice System facilities, community correctional programs, including work-release programs and halfway houses run by a correctional agency, alternative sentencing programs such as “boot camps,” or detention centers. The following are not examples of correctional settings: residential substance abuse treatment centers or halfway houses run by a noncorrectional agency.

Completing enrollment and 2 program sessions before release
Project START consists of enrollment and 6 program sessions. Each session includes a set of required tasks to be completed with every client. The following is a brief description of the activities to be completed before a participant is released from a correctional facility.

Enrollment. Enrollment is conducted inside the correctional facility within 60 days before release. Staff discusses with potential clients eligibility requirements. Staff provides potential clients a thorough overview of the program and answers any questions they may have. If clients decide to enroll, staff completes all enrollment paperwork, including agreement for services, intake form, locator form, and all necessary release-of-information sheets.

Session 1: HIV/STD/hepatitis risk assessment. Session 1 is conducted inside the correctional facility after enrollment and within 60 days of release. It includes 1) basic information on HIV/STD/hepatitis transmission and prevention education and a condom demonstration, 2) an HIV/STD/hepatitis risk assessment and individualized risk-reduction plan, and 3) HIV/STD/hepatitis educational brochures and facilitated referrals as needed. If allowed in the correctional facility, condoms and lubricant can be made available.

Session 2: transitional planning. Session 2 is conducted inside the correctional facility after session 1 and within 30 days of release. It includes 1) a review of the HIV/STD/hepatitis risk-reduction plan developed in session 1; 2) an assessment of other transitional needs such as housing, employment, substance abuse treatment, clothing, and food; 3) development of a transitional plan based on problem-solving and goal-setting worksheets; 4) specialized planning for the first 48 hours after release; and 5) facilitated referrals to community resources as needed. If allowed in the correctional facility, condoms and lubricant can be made available.

Completing 4 program sessions after release in the community
The following is a brief description of the activities to be completed after a participant is released back into the community.

Session 3: immediate post-release. Session 3 is conducted after release. It takes place in the community as soon as possible and ideally within 48 hours of release. It includes 1) discussion of clients’ experiences since release, 2) update and revision of risk-reduction and transitional plans based on clients’ experiences and needs, 3) facilitated referrals and linkages to longer-term community resources, as needed, and 4) providing condoms and lubricant.

Session 4: continued risk-reduction and transitional planning. Session 4 is conducted after release in the community, ideally 3 to 6 weeks after release, depending on the goals and needs of the client. It includes 1) review of clients’ progress with their risk-reduction and transitional plans, 2) update and adjustment of plans based on clients’ experiences and needs, 3) facilitated referrals and linkages to longer-term community resources, as needed, and 4) providing condoms and lubricant.

Session 5: continued risk-reduction and transitional planning. Session 5 is conducted after release in the community, ideally 6 to 8 weeks after release, depending on the goals and needs of the client. It includes 1) review of clients’ progress with their risk-reduction and transitional plans, 2) update and adjustment of plans based on clients’ experiences and needs, 3) facilitated referrals and linkages to longer term community resources, as needed, and 4) providing condoms and lubricant.

Session 6: final planning and closure. This final session is conducted after release in the community, ideally 10 to 12 weeks after release, depending on the goals and needs of the client. It includes 1) final review and adjustment of the risk-reduction and transitional plans based on the clients’ experiences and current needs, 2) formal closure with clients, including a review of client successes and identification of next steps, 3) facilitated referrals and linkages to longer term community resources, as needed, and 4) providing condoms and lubricant.

Completing additional sessions
In some cases, additional sessions may be scheduled with clients when both the client and staff feel such sessions would be useful. These additional sessions are not required and not intended to extend the time that a client is in the program. Thus, all of the additional sessions should be scheduled during the 4- to 5-month period that the client is in the program. While for sessions 1 through 6 there is a strong preference to meet with clients face-to-face, CBOs can choose to conduct these additional sessions over the phone.

Additional sessions may occur before the client is released when follow-up is needed on facilitated referrals, community resources, and scheduled appointments that were identified through the transitional needs assessment. Additional sessions may also be needed before release if a client’s release date is extended after he or she has completed the 2 pre-release sessions. The staff member and client may want to reconnect before release to review the risk-reduction and transitional plans.

Additional sessions may occur after the client is released when a client is having a difficult time adjusting to the transition back into the community and is in need of additional resources and support. Additional sessions may also be needed after release if a client has a life event such as drug use, relationship breakup, personal injury, or a death in the family and is in need of immediate support or if a client has been reincarcerated and is about to be released again. The client may wish to have an additional session to review a new transitional plan and gather additional community resources.

Providing condoms
Providing condoms and lubricant is required in post-release sessions. While not every client may be ready or willing to use condoms, program staff must provide prevention materials, including condoms, for all clients in every post-release session. Some clients may decline to accept prevention materials after 1 session but may accept them at a later session. For clients who are not ready to use condoms, program staff may suggest that clients offer them to their friends.

Condom use should be discussed in the pre-release sessions. Most correctional facilities will not allow condom distribution, but some do. CBOs must check with their local correctional facilities before they start this program to see if condom distribution inside the facility is an option. If correctional facilities will not allow condom distribution, CBOs can see if the facility provides resource packets at release. If so, CBOs may wish to ask the facility if they can include condoms and lubricant in these release packets. Given the high rate of sexual activity in the first few hours and days of release, having condoms available in these release packets can reduce risk for Project START clients.

The original research of Project START was conducted with young men leaving prisons. Because the program is based on the needs and circumstances of each client, Project START can be adapted to meet the unique needs of wide variety of people who are leaving various correctional settings, including men and women, people of all ages, and people who are HIV-positive and people who are HIV-negative.

Adapting the Target Population
If CBOs are planning to use the Project START program with women or men of different ages, they may need to adjust the program to meet the specific needs of these communities. For example, for female clients, agencies may want to add information on women’s health issues (e.g., breast self-exams, breast and cervical cancer) as well as referrals to domestic violence counseling services. In addition, CBOs may want to add prevention education and information on other health issues, such as hypertension, diabetes, and cancer. By adding this information, programs provide a more holistic approach to HIV/STD/hepatitis prevention. They are also more likely to keep clients interested in the program by meeting their clients’ most immediate needs.

Adapting for HIV-Positive Clients
In the original research, most Project START participants were HIV-negative. If CBOs are working with HIV-positive clients, they may need to change or add to some of the materials. The Project START Risk Assessment and Immediate Release Checklist have been adapted to include specific questions for HIV-positive clients. CBOs may also need to add staff training to reflect specific issues of concern for HIV-positive clients. Such changes may include adding information on the need to take medication consistently, links to community medical providers, discussions of disclosure, and transmission prevention.

If CBOs are considering serving HIV-positive clients, they need to consider the following issues in each part of the program:

• How and where people living with HIV are incarcerated in a correctional system.
• Confidentiality of HIV status in a correctional facility.
• Recruiting HIV-positive clients in a correctional facility without compromising information on the health status of an inmate to other inmates.
• If an agency is identified specifically as an HIV/AIDS service organization, the CBO needs to be aware of how this identity will be perceived by people who are incarcerated and by the staff that works in the correctional facility (i.e., clients who are seen meeting with the program staff may be perceived to be HIV-positive).

People
Project START needs the following staff positions:

• 1 full-time (or 2 half-time) experienced counselor or case manager to conduct all of the direct-service intervention activities.
• 1 part-time (40% time) program manager to provide program oversight, work as a liaison to the correctional facility, and oversee quality assurance and evaluation activities.
• 1 part-time (20% time) program assistant to provide administrative support for all staff and maintain up-to-date facilitated referral database and community resource guides.

Project START can also include 1 part-time (25% time) peer outreach worker to research possible agencies to be used for facilitated referrals and provide support for ongoing contact with clients, including street outreach and following new admissions to local jails and prisons.

The staff should be familiar with HIV/STD/hepatitis prevention activities and the specific needs of people being released from correctional settings.  Not everyone who can provide health education and prevention programs can work successfully in a correctional setting. Likewise, not everyone who can work in a correctional setting is able to provide quality health education, prevention, and transitional programs.

All program staff directly involved in intervention activities (e.g., case managers, counselors) should attend the 32-hour Project START facilitators’ training conducted by CDC’s training partners, the STD/HIV Prevention Training Centers. Program supervisors who oversee the intervention and supervise the program staff are also encouraged to attend the training. Program managers, agency administrators, and others who are interested in learning more about the intervention are encouraged to read the Project START starter kit found at The Diffusion of Effective Behavioral Interventions (DEBI).

A Note About Staffing: People who have been incarcerated or have a family member who has been incarcerated are often interested in working with Project START. While they can provide valuable insight and empathy with the clients, CBOs may have difficulty getting security clearance for them to enter the correctional facility. CBOs need to find out the facility’s policy on criminal backgrounds, incarceration, and clearance before they post positions. CBOs should conduct clearance checks early in the hiring process.

Space
Project START program sessions are designed to take place in a confidential and secure location that is appropriate for a one-on-one meeting between a staff member and a client. Working with a correctional facility to find a space that is appropriate for Project START can be challenging. Most correctional facilities were not built with service as a consideration, and program space is limited.

CBOs must find a space that provides the most privacy without endangering staff safety. This may mean being flexible about when an agency can deliver the program. For example, an agency may be able to use a classroom or counselor’s office that is vacant during certain times. Project START also requires agencies to find safe, convenient, accessible, and confidential space in the community for program sessions after clients are released.

Other
Funding
The cost of Project START will vary according to regional and local differences. When implementing Project START, agencies should first consider their own budget and available funding and determine how many participants the agency would like to serve. A reasonable estimate is to start with a maximum of 25 clients per case load at any time for each full-time program staff member. Given time for recruitment, enrollment, and the 5-month service cycle of the program, this estimate will allow an agency to serve approximately 50 clients per year per full-time program staff member.

Each participant has a minimum of 6 contacts with the CBO, so if a CBO serves 100 participants per year, it equals a minimum of 600 contacts. CBOs need to consider staffing, cell phones and other communication expenses, incentives, supplies, educational materials, and transportation costs to serve this many clients.

Transportation
Transportation may be required for clients and program staff, depending on where Project START sessions or referral services will be implemented. In metropolitan areas, subways or bus tokens should be made available to participants, both as incentives and as insurance that they will attend the sessions and facilitated referrals. In rural areas, consideration should be given to providing funds or vouchers for gasoline. Organizations may also provide transportation services for participants if policies allow.

Supplies
To implement Project START, CBOs will need the following supplies:

• Client files.
• Client forms.
• Client worksheets.
• Health education brochures from local health departments.
• Community resource guides.
• Identification applications (such as driver’s license forms or social security applications).
• Pens or pencils.
• Evaluation forms.
• Condoms (male and female).
• Lubricant.

Partnerships
Develop partnerships with other organizations as needed.

Memoranda of agreement
Memoranda of agreement should be completed with all partnering community service providers to identify what roles and responsibilities each party will have in referrals for Project START participants.

Incentives
Incentives are not a core element or key characteristic of Project START, so an agency is not required to provide them. Still, CBOs may use incentives to keep clients engaged, and they should use formative evaluation to decide which incentives would be most helpful for their clients. CBOs may hold a focus group with potential clients to find out what good incentives might be. CBOs may also ask their community advisory board for input on good incentives and possible resources for donations. CBOs may ask local businesses to donate incentives to help offset costs. Possible incentives for Project START clients include the following:

• Phone cards or prepaid cell phones.
• Cash reimbursements for travel or child care expenses during program sessions.
• Transportation passes or tokens.
• Toiletry items, such as soap, shampoo, deodorant, toothbrush, toothpaste, combs, or razors.
• Grocery store or other food vouchers.
• Other store vouchers.
• Restaurant vouchers.
• Movie passes.
• Tools for work.
• Haircut gift certificates.
• Baby care items, such as diapers, wipes, diaper cream, baby wash, formula, or bottles.
• Clothing and shoes, especially socks and underwear.
• Coats, hats, gloves, and boots, especially for cooler climates.
• School and work items, such as paper, pencils, pens, notepads, and erasers.
• Backpacks or duffle bags.
• Quarters for laundry and laundry soap.
• Household items (e.g., towels, laundry baskets, kitchen supplies).

Referral networks
Having a solid referral network if the CBO cannot provide a service, especially HIV and hepatitis C counseling and testing, is vital to the success of Project START. Given the many different needs of clients coming out of correctional facilities, implementing agencies should identify as many community partners for client referrals as possible. Examples of referral services include housing/shelter, substance abuse treatment programs, job training and placement programs, food pantries, or local health clinics. These services should be secured through a memorandum of agreement with each local provider.

The population recruited for Project START is incarcerated people who are getting ready for release back into the community. Recruiting clients in a correctional setting can be challenging. The correctional facility can give feedback on best practices and procedures. Incarcerated people can also provide useful information. They can give feedback on where best to recruit, good language for recruitment materials, and ways in which they can help recruit participants. They may also help CBOs develop ways to identify the clients who could most benefit from the program.

The following are examples of participant recruitment activities in correctional facilities:

• One-on-one outreach in recreational yards and in housing units.
• One-on-one outreach by incarcerated people who have been educated about the program, including peer health educators and inmate advisory committee members.
• Targeted referrals from correctional staff, including social workers, correctional counselors, substance abuse counselors, reentry coordinators, discharge planners, nurses, doctors, and teachers.
• Referrals from past or current clients who are either inside the facility or who have been released and still have contact with potential clients in the facility.
• Referrals from other service providers and programs in the correctional facility.
• Flyers posted in various parts of the facility, including housing units, program areas, classrooms, recreational sites, hospitals, and libraries.
• Information sessions at other facility events, classes, and treatment groups.
• List of people who are to be released in the next 60 days obtained from the correctional facility.

Confidentiality
The issue of confidentiality is different in a correctional facility than in a traditional community-based organization. The correctional facility may be concerned that confidential meetings can be a safety risk. Every effort should be made to discuss with the correctional facility the need for confidentiality and to develop a system to ensure the highest level of confidentiality for all program participants. This system should take into consideration private meeting space and storing paperwork outside the facility. In addition, before sharing any information with another agency to which a participant is referred, signed informed consent (or a release of information) from the participant or his or her legal guardian must be obtained.

Cultural Competence
CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profiles of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to different cultures. In addition, they should offer materials and services in the preferred language of participants, if possible, or make translation services available, if appropriate. CBOs should facilitate community and participant involvement in designing and implementing prevention services to ensure that cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. (Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services).

Data Security
To ensure data security and client confidentiality, data must be collected, reported, and stored according to CDC requirements. “Data” is defined as all information collected from or on behalf of the client (e.g., client intake forms, risk assessments, and PEMS evaluation forms).

Informed Consent/Agreement for Services
CBOs must have a consent or agreement for services form that carefully and clearly explains (in appropriate language) 1) all parts of the program, including client and staff responsibilities, 2) potential risks and benefits of the program, 3) the agency’s confidentiality policies and practices, 4) that participation is voluntary and clients are free to withdraw from the program at any time without consequences, and 5) the procedures for making any complaints about the program. Individual state laws apply to consent procedures for minors and mandated reporting of child or elder abuse or neglect, but at a minimum, consent should be obtained from each client and, if appropriate, a legal guardian if the client is a minor or unable to give legal consent. Documentation of this informed consent or agreement of services must be maintained in the client’s record.

Legal and Ethical Policies
If Project START is implemented with HIV-positive clients, by virtue of participation in Project START, clients will be disclosing their HIV status. CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization’s responsibilities if a client receives a positive HIV test result and the organization’s potential duty to warn. CBOs should also know the correctional facility’s policies and procedures regarding HIV status (such as housing and work assignments and restricted visiting privileges); CBOs are obligated to inform clients of the implications of disclosing HIV status in a correctional facility.

Linkages of Services
As part of recruitment, health education, and risk reduction, Project START staff must link participants whose HIV status is unknown to counseling, testing, and treatment services and people living with HIV to care and prevention services. CBOs must develop ways to assess whether and how frequently the referrals made by their staff members are completed.

Personnel Policies
CBOs conducting recruitment outreach, health education, and risk reduction must establish a code of conduct for employees. This code should include, but not be limited to, the following: do not use drugs or alcohol, do use appropriate behavior with program participants, and do not loan money to program participant or borrow money from program participants. Additional personnel policies may be directed by clearance procedures and training from the correctional facility, such as disclosing criminal records of intervention staff to the correctional facility and inappropriate behaviors while inside a correctional facility.

Safety
CBO policies must exist for maintaining the safety of workers and participants. Additional safety procedures may be required on the basis of correctional facility safety training and policies. Plans for dealing with medical or psychological emergencies must be documented.

Selection of Target Population
CBOs must establish criteria for, and justify the selection of, the target populations. Selection of target populations must be based on epidemiologic data, behavioral and clinical surveillance data, and the state of local HIV prevention plans created with input from sate or local community planning groups. Selection criteria may also include boundaries of agency service areas. This selection must be consistently maintained among potential program participants. In addition, an agency that wishes to conduct Project START may specify that they will serve only those inmates released into a particular service area, such as a particular community or city. The agency staff will need to be clear with prison officials that they will target only those people who will be released into the agency’s service area and that the agency will not serve every prisoners eligible for parole.

Volunteers
If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker’s compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

The following quality assurance activities should be in place when implementing Project START.

Attributes of Team Members
Team members should be familiar with the needs of people being released from correctional settings (e.g., parole/probation, substance abuse prevention and treatment, homelessness and mental health issues). They should also be familiar with the “culture of corrections” and with HIV, STD, and hepatitis prevention. Team member should have good oral communication skills and personal characteristics that facilitate communication (e.g., nonjudgmental attitude, active listening skills, friendly, outgoing, and trustworthy personality).

Implementation Plan
A strong component of quality assurance is preparing a plan to implement Project START. A comprehensive implementation plan will facilitate understanding and buy-in from staff and increase the likelihood that the intervention will run smoothly.

Leadership and Guidance
Someone from the CBO should provide hands-on leadership and guidance for the intervention, from planning through implementation. In addition, a decision maker from the CBO should provide high-level support, including securing resources and advocating for Project START.

Session Review
CBOs should have in place a mechanism to ensure that all session protocols are followed as written. Quality assurance activities can include 1) key staff or supervisors directly observing sessions, 2) audio-taping sessions, or 3) asking program staff to complete forms that include detailed notes and checklists of topics covered. Reviews should focus on adherence to session objectives and content, adherence to Project START core elements, use of program tools, accessibility and responsiveness to expressed client needs, and process elements (e.g., time allocation, clarity, use of open-ended questions).

Record Review
Selected client record reviews should focus on assuring that 1) agreement-for-services forms are included for all participants, 2) release of information forms have been signed by clients in the event of information sharing, 3) contact forms have been updated to effectively maintain contact with clients on release, and 4) session forms are completed in their entirety to ensure that clients and staff are meeting all session objectives.

Clients and Staff
The intervention must meet the needs of CBO clients and staff. Clients’ satisfaction with the intervention and their comfort should be assessed at each session. Staff who are implementing Project START can develop their own quality assurance checklist to help staff identify, discuss, and solve problems.

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures.  Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting.  PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements.  Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

1. Grinstead O, Eldridge G, MacGowan R, Morrow K, Seal D, Sosman J, Zack B, Project START Study Group. An HIV, STD and hepatitis prevention program for young men leaving prison: Project START. Journal of Correctional Health Care. 2008;14(3)183–196.
2. Wolitski RJ, Project START Writing Group. Relative efficacy of a multi-session sexual risk-reduction intervention for young men released from prisons in 4 states. American Journal of Public Health. 2006; 96:1854–1861.

Project START: HIV/STD/hepatitis prevention for young men being released from prison. Science to Community Report, Prevention #12. San Francisco, CA: University of California San Francisco, Center for AIDS Prevention Studies; 2004.

Zack B, Kramer K. What is the role of prisons and jails in HIV prevention? Fact Sheet 13R. San Francisco, CA: University of California San Francisco, Center for AIDS Prevention Studies; 2009.

For more information on technical assistance or training for this intervention, please visit The Diffusion of Effective Behavioral Interventions (DEBI).

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