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Summary of Intervention:
Philadelphia FIGHT, in partnership with Action AIDS and the Center for Mental Health Policy and Services Research at the University of Pennsylvania, proposes to increase capacity and enhance coordination of services for people living with HIV/AIDS within the Philadelphia Prison System and once released through a Healthcare Linkage Program. Our program will begin October 1, 2007 and will offer five core services: 1)in-reach within the nine local jails; 2) ex-offender case management services initiated in the jails and continued at Action AIDS; 3) in-jail discharge planning ; 4) an ex-offender HIV primary care clinic at the Jonathan Lax Center; 5) a 5 week patient education program housed at FIGHT. All services will be coordinated through weekly partner case conferences, informed by a multi-agency task force, and refined and disseminated through data collection and evaluation results.

Target Population:
This program will serve the estimated 5-10 % HIV-positive population in the Philadelphia Prison System (PPS), which despite its name is the county jail comprised of 9 institutions. While seroprevalance data generally finds HIV rates of 1, 2, and 3% in jails, voluntary testing by the AIDS Activities Coordinating Office (AACO) has consistently found higher rates in PPS. These HIV-positive inmates are predominantly African American men from impoverished communities, with some coming from neighborhoods in which 76% of people live below 200% of the poverty line. Many inmates experience substance dependence problems and mental illness, including serious mental illness. Approximately 80% of those incarcerated have a history of substance abuse or dependence, with 37% of inmates incarcerated for drug related offenses. While this program would serve the city of Philadelphia, our services would be concentrated in areas in North Philadelphia, West Philadelphia, and South Philadelphia, among the poorest minority neighborhoods in the city, as well as some parts of central Philadelphia. These neighborhoods account for 52% of all AIDS cases reported in Philadelphia.

Within PPS, healthcare services are offered by Prison Health Services (PHS). When released, ex-offenders need increased access to services to access that are tailored for their specific needs. The Healthcare Linkage Program will identify and link inmates and ex-offenders to care in a more timely and effective manner with services that are specific to their needs and priorities through increased capacity - more staff, inter-agency coordination, and more dedicated programs - to result in increased coordination of services to assure that individual clients are linked to care.

Goals and Objectives:
Goals and objectives include establishing partnerships among key organizations; creating a discharge planning and case management system that will follow clients from jail to the community; establishing an ex-offender clinic at the Jonathan Lax Treatment Center serving HIV+ people; establishing a coordinated team approach to support this collaboration; implementing a working empirical evaluation infrastructure that meets national multi site needs and local planning needs; implementing national and local evaluation studies and substudies; assuring confidentiality and planning for sustainability.