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Correctional facilities concentrate populations that are at risk for HIV infection: persons of color, persons with substance abuse histories, and persons living in poverty.1,2 As a result, the prevalence of HIV among US incarcerated populations is five to seven times that of the general US population.3,4 Furthermore, about 25% of people living with HIV in the US have been incarcerated.5 These statistics support the need for access to effective means of HIV prevention and harm reduction strategies in correctional facilities. Condoms are highly effective at preventing the transmission of HIV.6 Despite the fact that there is a growing consensus that in-custody HIV transmission is not trivial,7 condoms are made available to only a minute fraction of the US prisoner population. The manner in which condoms are currently made available to prisoners in California varies widely. In the Los Angeles County Jail, the Center for Health Justice distributes condoms to a segregated gay male population only, one condom per week by request. In San Francisco, prior to this project, condoms were distributed by request through the Forensic AIDS Project’s public health staff in one-on-one health counseling sessions, one per person, per request.

CAPS and Centerforce, a community-based organization that has been providing services to prisoners and their families for thirty years, have been collaborating since 1993 to design and evaluate HIV prevention interventions for incarcerated men and their female partners. Our previous work with male prisoners includes the evaluation of a peer-led HIV education orientation for arriving prisoners; development and evaluation of a prerelease intervention for men leaving prison; development and evaluation of a health promotion intervention for HIV+ prisoners preparing for release;3 and a multi-site study to conduct formative research and develop and test an HIV, STD and hepatitis intervention for young men preparing for release from prison. Early in the course of these studies, men expressed a need for HIV prevention interventions specifically tailored for the needs of the women with whom they were in romantic and sexual relationships. In response, we conducted formative research with women visiting men imprisoned in a California state prison and we piloted a single session intervention designed for this population that was taught by a peer educator. Our formative work with women visiting incarcerated men indicated that it was feasible to engage women in intervention and research evaluation activities. However, a single-session intervention did not have a measurable effect on the HIV risk behavior of study participants. We decided to develop a multi-component intervention targeting the specific needs of women with incarcerated male partners. We designed and evaluated Health Options Mean Empowerment (HOME), an intervention to reduce HIV risk among women whose male partner was being released from state prison.

HIV+ persons confront a unique set of challenges and chronic stressors, including stigmatization, alienation from family and friends, complex treatment regimens, and, often, debilitating side effects as they attempt to manage the psychologic and physiological consequences of their condition. For persons living with HIV, elevated distress and low social support take on added importance because they can accelerate disease progression. Helping HIV+ people to reduce stress and adhere to their medical care may in turn help to reduce their risky behavior. The ability to cope successfully with a chronic illness such as HIV disease is influenced by a number of social and psychological factors. Stress and coping theory provides a framework for studying these factors and for intervention. Coping research draws attention to the co-occurrence of positive and negative psychological states and recognizes the importance of encouraging coping processes that help to sustain positive psychological states in the context of stress. We evaluated a coping intervention, Coping Effectiveness Training (CET), designed to assist HIV+ gay men in sustaining psychological health despite the ongoing stress associated with HIV infection. The study was a randomized clinical trial of an innovative, theory-based coping intervention. The research questions addressed the problems of maintaining intervention effects, evaluating intervention effects on quality of life, health care utilization and adherence to medical care, and testing new advances in stress and coping theory.

As people are living longer and healthier lives with HIV, the risk of HIV transmission through unprotected sexual intercourse or sharing injection equipment continues to grow. While the general consensus is that most people who know they are HIV+ are careful to avoid transmitting the virus, it is estimated that one third of HIV+ gay/bisexual men continue to engage in unprotected sex. There is now a growing call to develop targeted and effective prevention strategies addressing the specific needs of people living with HIV.

The Implicit Theory project was designed to capture how HIV prevention providers delivering services think behavior change in their clients happens, what we refer to as providers’ implicit theories. This is important for many reasons. To begin with, the providers work directly with clients and were often peers of these clients. They are directly interacting with their clients and may be able to even witness when change has occurred. The providers’ position as peer or former peer, as the practice of hiring from the community that one wants to serve is very popular among HIV prevention organizations, is also key. This position provides insight and familiarity about the context and complexities of clients’ lives that is unique to providers. But the most compelling reason to capture this is that this is what providers are actually doing. Regardless of what researchers are studying or what funders are funding, we found that the providers we interviewed are out in the field acting on what they believe helps change behavior. Providers’ implicit theories drive their services, and therefore, it’s important to understand these implicit theories.