ABSTRACTThe proposed Free World Bound Texas (FWBTX) project responding to CDC-RFA-PS20-2011 focuses on creating a sustainable, statewide network to successfully facilitate re-entry and continuity of care and sustained HIV viral suppression for Persons with HIV (PWH) released from the Texas Department of Criminal Justice System. The project will bridge prison-to-community transition through developing capacity through an extensive network of partners throughout the state of Texas, highly mobile intervention teams and virtual, synchronous audiovisual interactions through telehealth. Partner sites will further be supported by educational opportunities to increase their infrastructure to serve the population of focus and through practice transformation to create a sustainable model of care. FWBTX efforts will focus on creating and strengthening infrastructures in areas that experience higher rates of re-entry among PWH transitioning from prison to the community. These areas include North Texas particularly Dallas County, Dallas TX and Tarrant County, Fort Worth TX; Travis County, Houston TX; Bexar County, San Antonio TX; and the counties of Brownsville, Harlingen and McAllen, TX in the Rio Grande Valley. The project will expand its areas of focus during the planning phase to include additional locations in Texas where rates of re-entry for PWH are also notable.FWBTX will develop and implement a systems-level approach to ensuring continuity of HIV medical care for PWH released from Texas state prisons into the community. FWBTX will implement effective, cost-efficient, culturally and linguistically appropriate, evidence based interventions focused on linkage to and retention in community HIV medical care, adherence to HIV treatment, suppression of HIV viral load, strategies for identifying PWH, and sex and drug injection partners/associates of program participants and linking them to necessary care including testing for HIV and sexually transmitted in
fections (STIs), as well as HIV and STI treatment, and prevention services.The project will include an evaluation study to further monitor and assess the impact of the project within the local care setting including partner-sites. The study will address the following key questions a) what sub-population disparities exist among the project population; and b) what changes occurred to support quality improvement. FWBTX will implement critical strategies to support the following outcomes:?Increase timely identification of PWH not linked to medical care within 20 days of post release by 85%;?Improve timely linkage to and continuity of HIV medical care and service delivery for PWH released from Texas prisons by 85%;?Increase retention in HIV medical care and sustained HIV vital load suppression for PWH released from Texas prisons by 85%;?Increase receipt of HIV medical care by HIV-infected partners and associated of PWH released from Texas prison by 85%; and?Increase receipt of HIV prevention services including PrEP, by HIV-negative partners and associated of PWH released from TX prison by 85%.