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Compendium of Evidence-Based Interventions and
Best Practices for HIV Prevention

Project START

BEST-EVIDENCE

Intervention Description

Target Population
Young men soon to be released from prison

Goals of Intervention

  • Eliminate or reduce risk behaviors for HIV, STD and hepatitis after release.

Brief Description

Project START is a 6-session individual-level HIV, STD, and hepatitis risk reduction intervention for men soon to be released from prison. It incorporates features of prevention case management, motivational interviewing, and incremental risk reduction. This intervention consists of 2 individual sessions conducted within 60 days before release and 4 individual sessions at 1, 3, 6, and 12 weeks after release. In the first in-prison session, the interventionist assesses the participant’s knowledge of HIV/AIDS, STD, and hepatitis, conducts a brief HIV-risk assessment, and helps the participant develop a personal risk-reduction plan. The interventionist also provides information, skills training, and referrals and helps to identify incremental steps towards risk reduction. The second in-prison session focuses on community reentry needs and referrals for housing, employment, finances, substance abuse, mental treatment, legal issues, and avoiding reincarceration. The post-release sessions involve a review of the previous sessions and discussion of the facilitators and barriers to implementing the risk reduction plan. Additional sessions are available for participants in the enhanced session as needed during the intervention period.

Theoretic Basis

  • Incremental Risk Reduction approach
  • Motivational Interviewing

Intervention Duration
The two pre-release sessions last 60 to 90 minutes each and are provided within 60 days prior to release from prison; the post-release sessions last 30 to 60 minutes and are provided approximately 1, 3, 6, and 12 weeks after release from prison, totaling 4-7 hours over the duration of the intervention.

Intervention Settings
The pre-release sessions are provided inside the prison; the post release sessions are conducted in community/private settings such as community based organizations. Some post-release sessions are conducted by telephone. For participants who are re-incarcerated, post-release sessions are provided in the prison or jail.

Deliverer
Men and women trained facilitators

Delivery Methods

  • Counseling
  • Goal setting
  • Problem solving
  • Prevention case management
  • Decision making

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Intervention Package Information

An intervention package was developed with funding from CDC’s Replicating Effective Programs (REP) Project. The intervention package and training are available through CDC’s Diffusion of Effective Behavioral Interventions (DEBI) project.

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Evaluation Study and Results

The original research study was conducted in 2001-2003 with participants from four state prison systems in California, Mississippi, Rhode Island, and Wisconsin.

Key Intervention Effects

  • Reduced unprotected sex

Study Sample
The baseline study sample of 522 incarcerated men is characterized by the following:

  • 52% African American, 23% White, 14% Hispanic, 12% other
  • 100% Male
  • 23% 18-21 years of age, 48% 22-25 years, 20% 26-29 years
  • 55% completed high school education or GED

Recruitment Settings
Eight state prisons

Eligibility Criteria
Men were eligible if they were: (1) 18-29 years old, (2) able to speak English, (3) had been or expected to be incarcerated for at least 90 days, (4) scheduled for release from prison within 14-60 days, (5) able to provide informed consent, (6) willing to provide post release contact information, and (7) expected to be released to an unrestricted environment in site-specific catchment areas.

Assignment Method
Men (N = 522) were assigned to 1 of 2 groups: Project START Intervention (n = 263) or single-session comparison (n = 259) – using an alternating sequence based on the month of recruitment (for prisons in California or Rhode Island) or the month of anticipated release (for prisons in Mississippi and Wisconsin) over a 24-month period.

Comparison Group
The comparison group received a single individual-level session, conducted approximately 2 weeks prior to release from prison, which consisted of a brief HIV-risk assessment and risk reduction plan. The interventionist provided information, skills training, and referrals as required and worked with the participant to identify incremental steps towards risk reduction.

Relevant Outcomes Measured and Follow-up Time

  • Sex behaviors were measured as number of times each type of sex was performed (e.g., vaginal, insertive and receptive oral sex, insertive and receptive anal sex) and number of times condoms were used for each type of sex. These behaviors were measured for each of the following types of partners: any, main, non-main, non-sterile injection drug users, and at-risk partners.
  • Sex behaviors were also measured for at-risk partners (defined as partners who ever injected drugs, ever had an STI, ever smoked crack, ever traded sex for money or drugs, currently had other sexual partners, HIV positive status) for each of the following types of partners: any, main, non-main, non-sterile injection drug users
  • Recent use of injection drugs
  • All outcomes were measured at 1 week after release (recall period: time since release from prison) and at 12 weeks and 24 weeks after release (recall period: time since previous assessment). The 1-week and 12-week assessments were both collected during the intervention, and the 24-week assessment translates to a 3-month follow-up for the intervention group. For the comparison group, the 1-week, 12-week, and 24-week assessments translate to approximately 3-week, 14-week (3.5-month) and 26-week (6.5-month) follow-ups, respectively.

Participant Retention

  • Project START Intervention:
    84% retained at week 1
    82% retained at week 12
    83% retained at week 24
  • Comparison:
    87% retained at week 1
    76% retained at week 12
    82% retained at week 24

Significant Findings
At 3 months after intervention, intervention participants were significantly less likely to report unprotected vaginal or anal sex at last sex (p < .05), with any partner (p < .05), with a main partner (p < .05) or with an at-risk partner at last sex (p < .05) when compared to comparison participants.

Considerations

  • The significant findings described above were based on data collected 3 months after the intervention for both groups, however, due to the difference in number of sessions between the two groups the outcomes were measured at 24-weeks post-release for the Intervention group and 12-weeks post-release for the Comparison group.
  • Given the low prevalence of injection drug use in both the intervention and comparison groups, analyses for this outcome were not performed.
  • Intervention effects were also found to be significant when comparing the 24-week post-release assessment for both treatment groups, however, the actual follow-up time since the intervention differs greatly by group and is over twice as long for the comparison group (as described above).
  • Intervention effects were not found to be significant at the 12-week post-release assessment, which was collected just prior to the final 12-week post-release intervention session for the Intervention group).
  • In California only, at the 12-week post-release assessment only (prior to the last session in the intervention group), the intervention group had a greater proportion of men reporting having been reincarcerated than the comparison men (p < .05), however, this finding could be attributed to site-specific differences in tracking procedures rather than the intervention itself.

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References and Contact Information

  • Wolitski, R. J., & The Project START study group. (2006). Relative efficacy of a multisession sexual risk reduction intervention for young men released from prison in 4 states. American Journal of Public Health, 96, 1845-1861.

    Researcher: Dr. Richard J. Wolitski
    Division of HIV and AIDS Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    1600 Clifton Road NE (MS E-37)
    Atlanta, GA 30333
    email: rwolitski@cdc.gov

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