Date Published: July 28, 2013
Publisher: Hindawi Publishing Corporation
Author(s): Ann Kurth, Irene Kuo, James Peterson, Nkiru Azikiwe, Lauri Bazerman, Alice Cates, Curt G. Beckwith.
The United States has the world’s highest prison population, and an estimated one in seven HIV-positive persons in the USA passes through a correctional facility annually. Given this, it is critical to develop innovative and effective approaches to support HIV treatment and retention in care among HIV-positive individuals involved in the criminal justice (CJ) system. Information and communication technologies (ICTs), including mobile health (mHealth) interventions, may offer one component of a successful strategy for linkage/retention in care. We describe CARE+ Corrections, a randomized controlled trial (RCT) study now underway in Washington, that will evaluate the combined effect of computerized motivational interview counseling and postrelease short message service (SMS) text message reminders to increase antiretroviral therapy (ART) adherence and linkage and retention in care among HIV-infected persons involved in the criminal justice system. In this report, we describe the development of this ICT/mHealth intervention, outline the study procedures used to evaluate this intervention, and summarize the implications for the mHealth knowledge base.
The criminal justice system in the USA comprised prisons, jails, and community supervision programs including probation and parole and incarcerates more persons than any other nation in the world which disproportionately affects persons of color, the economically disadvantaged, and those who suffer from mental illness [1, 2]. In 2011, there were close to 7 million persons within the CJ system, among which 1.5 million were in prison, 4.5 million were on probation or parole, and close to 750,000 were held in local jails . Prisons typically incarcerate sentenced individuals for periods of one year or greater, whereas jails incarcerate the majority of persons for short periods of time (days, weeks) before releasing them back to the community. A significant proportion of arrests are related to drug and alcohol use , with more than 50% of inmates meeting the DSM-IV criteria for drug dependence or abuse . Due to drug laws and punitive sentencing, the criminal justice system is a nexus for large numbers of substance using individuals, many of whom are living with or are at risk for HIV .
We took a user-centered design  approach to adapt two well-developed ICT tools to create the CARE+ Corrections intervention. These tools included the CARE computerized counseling platform (Resources Online, Seattle, WA) and CommCare (Dimagi, Boston MA), an SMS text messaging platform. CARE is a computer-based counseling platform offering HIV risk assessment, tailored counseling, and health promotion planning in versions designed to facilitate rapid HIV testing (Test CARE) and to support ART adherence and secondary HIV prevention (CARE+). The platform uses Microsoft. NET framework with a MySQL backend; a web-based version is now available. The platform was developed using street intercept surveys to review paper prototypes , followed by pilot testing and then RCTs. The platform uses narrated self-interviewing to ascertain behavioral risk, assess self-efficacy/motivation, and provide tailored feedback on specific risk behaviors. Prior to developing a health promotion plan around sexual risks or medications, users watch skill-building videos appropriate to their stage of readiness for behavior change. The CARE tool now exists in several forms with different counseling content (rapid HIV testing and primary HIV risk reduction for persons with unknown HIV status and ART adherence and secondary risk reduction for persons already known to be HIV-infected), and it has been adapted for use in several languages (English, Spanish, Kiswahili) and has been used in multiple settings including HIV clinics, community-based organizations, hospitals/emergency departments, and mobile HIV testing services [16–18]. The CommCare SMS platform developed by Dimagi was originally used for data collection by community health workers . In order to make it accessible to all populations, content in the CARE+ tool and the SMS texting intervention is at the 5th grade reading level.
We will test whether our combined ICT intervention consisting of an interactive tablet-based counseling tool delivered in jail before release or immediately after release combined with an SMS text messaging intervention delivered in the community can support this highly vulnerable group of returning citizens who are living with HIV. These returning citizens often are struggling with active substance use and facing challenges related to poverty, unemployment, and unstable housing all of which create barriers to being retained in continuous HIV care . We hypothesize that this mHealth tool will enable preparatory self-planning and provide ongoing support during community reentry. If found effective and cost effective, we anticipate wide-spread dissemination to criminal justice systems and related community-based organizations that may help address the needs of this vulnerable population and reduce the burden of HIV transmission in the community.