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    • A man named, Al Brown, standing on a street in LA
      Al Brown is a “health navigator” in a joint study of the LA County Sheriff's Department, LA County Department of Public Health and UCLA.

Exit Strategy

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Providing a relatable peer to assist HIV-positive men with their transition from jail to society promises a smoother transition – and improved community health.

Al Brown is used to the surprised looks on the faces of his clients – men taking their first steps of freedom following release from L.A. County jails – when he meets them at the gate. Brown is a “health navigator” in a joint study of the Los Angeles County Sheriff’s Department, Los Angeles County Department of Public Health and UCLA aiming to improve the likelihood that these men, who have tested positive for HIV, will continue with life-sustaining medical care once they re-enter society. He’s gotten to know the men during their incarceration, and promised to be there when they got out. Nonetheless, when they find Brown waiting upon their release – often with a cell phone and their $25 study participation fee to help get them started – many are taken aback.

“When incarcerated people see guys in suits and ties or wearing badges, they think, ‘How could you possibly understand what I’ve been through?’ When I talk to them, they know I went through the fire and came out on the other side.”  —Al Brown

“A lot of people have been failed by the system,” Brown says. “Often, I’m the first person to actually follow through with them.”

Brown has walked in his clients’ shoes. Imprisoned at 16 for being “at the wrong place at the wrong time,” he spent many years behind bars. Brown dramatically turned his life around upon his release, ultimately landing a full-time position with the Los Angeles-based Center for Health Justice. Now he’s a health navigator assisting formerly incarcerated men as they struggle to begin their lives anew. “Many of these people haven’t learned how to live in society,” says Brown. “Who better to assist them than somebody who’s walked the walk.”

In efforts to address the HIV epidemic in U.S. communities, from a public health perspective few populations are as important to target as men in the criminal justice system. Each year, approximately one in seven people infected with HIV passes through a correctional facility. “The jail system represents an important aspect of the epidemic that hasn’t been addressed sufficiently,” says Dr. William Cunningham, a professor at the Fielding School and in the David Geffen School of Medicine at UCLA. “Recidivism rates for HIV-positive men are extremely high – it’s like a revolving door between the community and the jail.”

Cunningham is leading LINK LA, a first-of-its-kind study of a strategy that employs health navigators such as Brown, who come from similar backgrounds as the study participants, to help ensure that the newly released men receive their care. In addition to addressing the health of these men as they re-enter society, the approach is designed to improve the health of the communities they live in by suppressing their so-called viral load (the level of circulating HIV in the blood), and thus reducing the likelihood that they will transmit HIV to others. If shown to be effective, the National Institutes of Health-funded randomized controlled trial could serve as a model for communities across the country.

William Cunningham, Mark Malek and Al Brown stand together smiling at the camera.
From left to right: Dr. William Cunningham, Dr. Mark Malek and Al Brown.

The study is part of a larger initiative of the National Institute of Drug Abuse promoting a new public health model known as “Seek, Test, Treat and Retain” for addressing HIV among criminal justice and other populations. “The old paradigm looked at prevention and treatment as two separate things,” Cunningham explains. Prevention involved strategies such as condom distribution designed to reduce transmission risk, whereas treatment efforts focused on making highly active antiretroviral medications available to HIV-positive people, on the premise that anyone with the disease would access medical care to get the life-saving drugs.

But study after study has shown that at least 20 percent of the HIV-positive population isn’t receiving care. Moreover, Cunningham and others have found that people with a history of incarceration – particularly African American and Latino men – are far less likely to receive HIV treatment. Under the new model, getting the HIV-positive population on antiretroviral drugs isn’t only a strategy to keep them healthy, but part of an effort to prevent the spread of the virus in the community. “The medications reduce the viral load,” says Dr. Mark Malek, director of infection control and epidemiology for the L.A. County Sheriff’s Department jail system and a member of the Fielding School faculty, who is part of the study. “This significantly reduces the likelihood that people who are HIV-positive will infect others if they engage in risky behavior.”

“The jail system represents an important aspect of the [HIV] epidemic that hasn’t been addressed sufficiently. Recidivism rates for HIV-positive men are extremely high – it’s like a revolving door between the community and the jail.”  —Dr. William Cunningham

Commonly, says Cunningham, incarcerated HIV-positive men receive treatment while in jail but fail to continue following their release, focusing instead on other basic concerns such as housing and transportation. Many among the incarcerated population also struggle with substance abuse and mental illness.

LINK LA looks to make a difference by establishing connections for the target population while they are jailed and sustaining those relationships beyond their release. “A lot of these men have unstable lifestyles, and incarceration is a chance to get their attention,” explains Malek. “They’re more lucid, they have time on their hands and they’re more apt to listen to someone talking to them about their health.” LINK LA, now in its fourth year, is based on the hypothesis that successfully reaching these men requires relatable peers – trained staff with backgrounds similar to the study participants, who can impress upon them the importance of taking medications to control their disease and provide hands-on guidance through the complex health care system. The health navigators, hired by the county public health department’s Division of HIV and STD Programs, provide social support and inspiration as well as practical assistance – going so far as to accompany the men on appointments as they make the transition back into the community – be it for substance abuse treatment, mental health services or following through on their HIV care.

“We bring a certain credibility to the program,” says Brown, who remains in regular face-to-face and phone contact with his clients for up to six months after their release. “When incarcerated people see guys in suits and ties or wearing badges, they think, ‘How could you possibly understand what I’ve been through if you’ve never been there?’ When I talk to them, they know I went through the fire and came out on the other side, and they start to believe they might be able to do that too.”

“Al helped me make the contacts I needed in order to get stable,” says one study participant, who describes being in daily contact with Brown for the first month after his release from jail earlier this year. “We made plans as to how I would progress. He listened to my problems without being judgmental, but at the same time if I had wanted to backslide, I don’t think Al would have accepted that.” 

The research team is conducting a rigorous assessment of the strategy – through interviews at the start of the study and after the participants have re-entered the community, as well as a review of medical records – to measure the men’s treatment- and prevention-related behaviors and health changes over time. They will also analyze re-arrest and jail recidivism, along with determining whether the intervention is cost-effective and prevents avoidable hospital and emergency room use. Says Cunningham: “If we can demonstrate that the costs of this program are offset in the bigger picture, that would make it more attractive.”

Al Brown and Mark Malek walking downtown skid-row in Los Angeles.

It’s often difficult to convince policymakers to invest in such efforts. “Public opinion hasn’t always supported devoting resources to inmates,” says Malek. “It’s very easy to demonize them.” But he argues that from a public health standpoint, few populations present as great an opportunity to make a difference. “We’re incarcerating people with drug habits, and you don’t make good decisions when you’re high,” Malek notes. “So they’re engaging in high-risk behaviors that lead to a high prevalence of sexually transmitted diseases, as well as high rates of infections and chronic diseases. Most of them are male, young, poor and minority. When they get out they return to crowded urban areas. If we are looking at ways to get a big bang for our buck, improving the health of this population so that we don’t have to spend a lot more when they and others end up in the hospital makes a lot of sense.”

“A lot of these men have unstable lifestyles, and incarceration is a chance to get their attention. They’re more lucid, they have time on their hands and they’re more apt to listen to someone talking to them about their health.”  —Dr. Mark Malek

Malek is helping to make future public health professionals aware of these issues by exposing his Fielding School students to the jail system. In his Epidemiology of Communicable Disease in Correctional Populations course (taught jointly with Emory University through a video link), he brings Brown in as a guest speaker. Then he takes his students on a field trip to the jail, walking them through all of the steps that inmates go through on their way in.

“It’s really eye-opening,” says Nazia Qureshi, a second-year MPH student in epidemiology who was so moved by the experience that she now works as an intern for Malek at the facility. “When you’ve never been exposed to incarcerated populations, it’s easy to ignore them. This was a reminder that these are human beings entitled to health care, just like the rest of us.”

LEARN MORE:
Epidemiology of Communicable Disease in Correctional Populations