The New York State (NYS) Department of Health (DOH), AIDS Institute (AI) approach outlined in our application represents an expansion of current services and supports provided to incarcerated and recently released Persons living with HIV (PWH) and those at risk for HIV across NYS. Our approach leverages long-standing collaborative partnerships with NYS Department of Corrections and Community Services (DOCCS) and community-based organizations (CBO) that work with PWH incarcerated or recently released from DOCCS facilities. The AI has a long-standing, 30-year history of working collaboratively with DOCCS and CBOs to serve incarcerated and recently released PWH and HIV-negative persons engaging in high risk behavior throughout the state through our Criminal Justice Initiative (CJI). Through our CJI programming, CBOs throughout the state provide in-facility pre-release linkage and navigation services, peer education and training, HIV/STI/hepatitis prevention, trauma informed supportive services, and anonymous HIV testing. In addition to pre-release services, three (3) CBOs provide community reentry linkage and navigation services for PWH who are releasing to the New York City metro area. Our project will ensure the same level of services can be provided to PWH returning to communities outside of NYC, specifically Upstate New York
(Hudson Valley, Capital Region and North Country, Central NY, Finger Lakes Region and Western NY). Following the NYC model, Linkage Specialists (LS), employed by our partner CBOs, will help PWH reentering Upstate New York (Upstate NY) communities navigate complex systems of care through their long-standing relationships with area medical, community-based, and social service providers. Barriers to reentry/engagement in care in UNY include lack of public transportation in more rural areas; fewer medical providers, mental health providers, substance use providers, HIV specialists, and other complex health and social/service providers. Existing CJI providers serving Upstate NY are well-established CBOs that offer a wide range of services and supports for PWH that can be accessed by recently released PWH. In addition to their own internal services, these CBOs have long-standing relationships with other medical and social service providers and DOCCS Community Supervision in their regions that ensure prompt access to medical and social services and supports for recently released PWH along with their partners and/or associates. Outcome measures will include post-release linkage to and retention in community HIV-related medical care and HIV viral load suppression. Outcomes to be monitored include: increased identification and monitoring of PWH incarcerated in state prison and projected to be released to the community within 6 months; increased pre-release HIV prevention and care planning for PWH incarcerated in state prison and projected to be released within 6 months; increased timely identification of PWH not linked to HIV medical care within 30 days after release; improved timely linkage to and continuity of HIV medical care and service delivery for PWH released from state prison; increased retention in HIV medical care and sustained HIV viral load suppression for PWH released from state prison; increased awareness of HIV status among partners and associates of PWH releas
ed from state prison who are living with HIV; increased awareness of risk for HIV among HIV-negative partners and associates of PWH released from state prison; increased receipt of HIV medical care by partners and associates of PWH released from state prison who are living with HIV; and increased receipt of HIV prevention services, including linkages to PrEP and STI / HCV screening, by HIV-negative partners and associates of PWH released from state prison. All specific, measurable project outcomes to be met are listed in our work plan.