Correctional Health Services Research Articles

212. Gonorrhea and Chlamydia Opt-Out Screening of Justice-Involved Females During Intake at the Los Angeles County Jail: The Pivotal Role of Correctional Health Systems

Abstract Background Chlamydia and gonorrhea are two of the most common sexually transmitted infections (STIs) worldwide, presenting major public health challenges and resulting in billions of dollars in direct medical costs in the U.S. Incarcerated females have a particularly elevated risk of these infections, which can result in significant clinical and public/community health-level sequelae if left untreated. On December 13, 2021, the division of Correctional Health Services began offering opt-out urogenital chlamydia and gonorrhea screening to all newly incarcerated females within the Los Angeles County Jail system. Methods We retrospectively analyzed electronic health record data for completed urogenital chlamydia/gonorrhea screening among newly incarcerated females between December 13, 2021, and May 31, 2023. We used multivariable logistic regression to examine the association of STIs and treatment non-initiation outcomes with various demographic and self-reported variables. Results Of the 13739 women offered STI testing, 10717 (78%) completed screening, with 1151 (11%) having a chlamydial infection, 788 (7%) having a gonococcal infection, and 1626 (15%) having either infection. In a multivariable model, result positivity was associated with age 18-34, reported houselessness, amphetamine use, and history of a positive prior treponemal antibody test. STI treatment non-initiation was associated with shorter length of stay for both chlamydial ([aOR] = 87.4, 95% CI (34.2, 223.2)) and gonococcal ([aOR] = 9.0, 95% CI (5.2, 15.7)) infections. Conclusion The STI screening and prevalence among female detainees tested at intake was many-fold higher than that of the general population. The implementation of routine opt-out STI screening and treatment of STI-infected people in carceral settings provides a unique and important opportunity to benefit the health of this high-risk population and has the potential to create a spillover effect that might benefit the surrounding community. Disclosures Loren G. Miller, MD MPH, Armata: Grant/Research Support|Contrafect: Grant/Research Support|GSK: Grant/Research Support|Merck: Grant/Research Support|Paratek: Grant/Research Support

"A different sense of what we do here, who we are and what we deliver": Provider perspectives on the effects of a change in governance of healthcare services in correctional facilities in British Columbia.

In 2017, British Columbia (BC) transferred responsibility for healthcare services in provincial correctional facilities from the Ministry of Public Safety and Solicitor General to the Ministry of Health. This study explored how healthcare leadership perceived the impact of the transfer on services, work-life, and job satisfaction. We conducted one-on-one interviews (n = 8) with healthcare managers and medical and administrative leadership within Correctional Health Services. Using the Two-Factor theory of job satisfaction as a framework, we applied Interpretive Description methodology to analyse interview data. Participants identified changes to four areas of the working environment: (1) staffing, equipment, and resources (2) systems of supervision and support (3) standards, policies, and quality improvement and (4) culture and orientation. These changes predominantly affected motivational factors of job satisfaction and were described as enriching the roles of managers and staff. Participants described improved autonomy and recognition of providers, increased quality of services delivered, and a shift toward patient-centred care. The perspectives of healthcare leaders provide new insight into the potential impact of transferring healthcare services in custody to a public healthcare system. Discussion of changes and their affects also provide practical learning for jurisdictions seeking to improve healthcare under a variety of governance and service-delivery models.

Exploring mental health comorbidities and opioid agonist treatment coverage among people in prison: A national cohort study 2010–2019

IntroductionDespite a high prevalence of opioid use disorder (OUD) among people in prison, there is little knowledge of how many receive the recommended opioid agonist treatment (OAT) and what characterizes those who receive OAT and those who do not when it comes to mental health comorbidities. We aimed to describe people with OUD in Norwegian prisons over a ten-year period and their OAT status, and to investigate comorbidity of mental health disorders stratified by gender. MethodsData from the PriSUD study, including all people (≥19 years old) imprisoned in Norway between 2010 and 2019, linked to national patient registry data, including ICD-10 codes. We calculated the prevalence (1-year and 10-year) of OUD and OAT, and mental health comorbidity stratified on OAT-status and gender. ResultsAmong the cohort (n=51,148), 7 282 (14.2%) were diagnosed with OUD during the period of observation. Of those, 4 689 (64.4%) received OAT. People with OUD had high levels of comorbidity, including other drug use disorders (92.4% OAT, 90.3% non-OAT), alcohol use disorder (32.1% OAT, 44.4% non-OAT) and any other mental health disorders (61.6% OAT, 68.2% non-OAT). The proportion receiving OAT among people with OUD increased markedly during the ten years of observation; from 35.7% in 2010–70.9% in 2019. ConclusionPeople with OUD, both receiving OAT and not, had substantially more mental health comorbidities than the non-OUD population. Understanding how the prison population changes over time especially in terms of mental health needs related to OUD, is important for correctional health service planning.

Transnational Trans Woman Inspires and Informs Evidence-Informed Interventions.

Transitional Care Coordination is an evidence-informed model program developed by New York City Correctional Health Services as a Health Resources and Services Administration Special Projects of National Significance Correctional Health Linkage Intervention. Using implementation science under this and subsequent demonstration projects, interventions were adapted and enhanced to address the transitional needs of people of Puerto Rican ancestry and to expand the network of care across the islands of Puerto Rico. These interventions were informed, in part, by a transnational trans woman of color of Puerto Rican ancestry living with HIV. A socioecological model framework and case study are used to illustrate how evidence-informed interventions are developed and adapted to address the needs of those served.

Substance Use Disorders and Antisocial Personality Disorder among a Sample of Incarcerated Individuals with Inadequate Health Care: Implications for Correctional Mental-Behavioural Health and Addiction Services.

Epidemiological estimates of substance use disorders (SUD) are critical for the planning of evidence-informed intervention and services. In this study, 250 incarcerated individuals in Nigeria were interviewed with the Mini International Neuropsychiatric Inventory (MINI) to diagnose SUD and antisocial personality disorder (ASPD). Most of the participants were males (97.6%), and the mean age was 35.4 (SD=13.5) years. Substance use disorder and ASPD were prevalent in 57.6% and 11.2% of the participants, respectively. Of those diagnosed with SUD, 35.2% and 22.4% had poly-SUD and mono-SUD respectively. Psychotic and dependence syndromes involving cannabis misuse were the most prevalent poly-SUD, and mono-SUD was characterized by alcohol, nicotine, and opioid dependence syndromes. Substance use disorder was more likely in participants charged with robbery and convicted, while ASPD was associated with prior and long-term imprisonment. There is a need for effective integration of treatment for ASPD/SUD into correctional mental health services in settings with inadequate health care using an appropriate model and a viable strategy.

Moving Forward Into the Future: Nurses and Nurse Leaders at Leading US Public Health System Implementing Foundational Transformation to Advance Health Equity.

The nation's largest public health care system, New York City Health + Hospitals (NYC H + H), is engaged in a fundamental transformation of its nursing culture, actualizing many of the recommendations in the National Academies, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. NYC H + H and its more than 9600+ nurses and 970+ social workers share a common public health mission, vision, and values to deliver essential health care services to the most vulnerable and disadvantaged members of society, regardless of ethnicity, culture, creed, gender, age, sexual orientation, income, immigration, or insurance status. This mission dovetails with all of the recommendations in the Future of Nursing report. Systemwide implementation of these recommendations is proceeding, with some programs further advanced than others. This article highlights the system's diversity, equity, and inclusion initiatives; nursing professional development; collaboration with academic partners; labor contract provisions to support recruitment and retention campaigns; technological advances to remove barriers to patient care; and nurse residency program and professional-shared governance implementation. NYC H + H safeguards 1.4 million patients annually, caring for 1 in every 6 New Yorkers through 11 essential hospitals, 5 post-acute care facilities, more than 70 community centers, and correctional health services in city jails.

Nursing Leadership at Nation's Leading Public Health System Addressing Health Equity and Social Determinants of Health at the Administrative Level and at the Bedside.

New York City Health + Hospitals (NYC H + H) is the largest public health care system in the United States, safeguarding 1.4 million patients annually, caring for 1 in every 6 New Yorkers through 11 essential hospitals, 5 post-acute care facilities, more than 70 community centers, and correctional health services in city jails. The 9600+ nurses and 970+ social workers represent the largest segment of the system's 40 000 employees, charged with delivering essential health care services to the most vulnerable and disadvantaged members of society, regardless of ethnicity, culture, creed, gender, age, sexual orientation, income, immigration, or insurance status. NYC H + H is in the process of reinventing nursing culture with a renewed focus on achieving true nursing excellence, emphasizing professional evidence-based best practices and a compassionate care delivery model, putting nurses in the forefront of all efforts to address the social determinants of health and the devastating consequences of health disparities. Systemwide implementation of foundational transformation is positioning nursing in the vanguard of the system's commitment to equity and diversity in the workplace, recognizing unconscious bias, calling out bigotry, and rooting out systemic racism, all key recommendations in the National Academies, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

Communication Over Incarceration: Improving Care Coordination Between Correctional and Community Mental Health Services.

Millions of people are incarcerated every year in the United States, many of whom have mental disorders and substance use disorders. Alongside the considerable churn of people into and out of U.S. jails and prisons, numerous barriers often impede information exchange between correctional and community mental health services, disrupting continuity of care and threatening the well-being of incarcerated and formerly incarcerated people. This Open Forum examines barriers to information sharing, a critical component of care coordination, between correctional and community mental health services and offers potential solutions to improve continuity of care in these contexts.

Outcomes of a NYC Public Hospital System Low-Threshold Tele-Buprenorphine Bridge Clinic at 1 Year

Background: This study evaluated clinical outcomes of a low barrier tele-buprenorphine bridge program for NYC residents with opioid use disorder (OUD) at 1 year during the coronavirus disease 2019 (COVID-19) pandemic. Methods and materials: This retrospective analysis of the NYC Health + Hospitals (NYC H + H) Virtual Buprenorphine Clinic registry assessed baseline demographic and clinical characteristics, rates of referrals to community treatment, and induction-related adverse events among city residents with OUD, from March 2020 to the end of March 2021. Results: The program enrolled 199 patients, of whom 62.3% were provided same-day visits (n = 124). Patients were enrolled in the program for a median of 14 days (range 0-130 days). Referrals sources included hospital and clinic staff (n = 83, 47.7%), word of mouth (n = 30, 17.2%), and correctional health or reentry services (n = 30, 17.2%). Induction-related adverse events were mostly limited to precipitated withdrawal symptoms (n = 21, 5%). Roughly half of patients were referred to community treatment (n = 109, 54.8%) and of those 51.4% (n = 56/109) completed at least one visit in community treatment. Discussion: Our experience indicates that a low threshold tele-buprenorphine bridge program in place of a safe and feasible approach to facilitating entry in community treatment for underserved people who use opioids in a large metropolitan area.

Implementation of a COVID-19 Infection Control Plan in a Large Urban Jail System.

When the COVID-19 pandemic hit the United States, the number of people confined in correctional facilities on a single day numbered 1.8 million. Incarcerated people are at an increased risk of contracting and spreading SARS-CoV-2. Recommendations from the Centers for Disease Control and Prevention on case recognition, management, isolation, and contact tracing are particularly challenging in jails because of the high turnover of incarcerated people. Beginning in late February 2020, the Department of Correctional Health Services in the Los Angeles County Jail system implemented a multipronged COVID-19 mitigation plan that was progressively amended in accordance with local and national recommendations. This plan entailed the creation of housing for people under investigation, SARS-CoV-2 screening upon entry, a mass-testing program, and identification and monitoring of medically vulnerable people. After the identification of the first laboratory-confirmed case on March 29, 2020, predictive models were generated to visualize potential disease spread and gain support for mitigation strategy planning, which forecasted approximately 3300-4600 cumulative cases during a 278-day period. From March 7 through December 31, 2020, the percentage positivity among unique people tested for SARS-CoV-2 was 11.6% (3933 of 33 921 tested). Among those screened at intake, the percentage positivity was 2.0% (502 of 25 702 tested). The ethnic distribution among people with a positive SARS-CoV-2 test result was largely representative of the overall jail population, and most people were asymptomatic. A sustainable, multifaceted mitigation plan that relies on collaboration among medical, custodial, and local public health personnel is essential for limiting the spread of SARS-CoV-2 infection in correctional facilities.

Latent class analysis of self-reported substance use during incarceration: Gender differences and associations with emotional distress and aggressiveness

IntroductionWe know little about the prevalence and patterns of substance use during incarceration, and we know even less about comparative substance use patterns by gender. To address these gaps in the literature, this study used latent class analysis (LCA) to identify substance use subgroups of incarcerated men (n = 1118) and women (n = 207). MethodsThe study drew data from six prisons in Spain. Participants completed a self-administered questionnaire with items probing for types of drugs used in the past three months, depression, anxiety, stress symptoms, aggressiveness, and perceived social support. ResultsSubstance use was common among incarcerated men and women, with tobacco, cannabis, and sedatives being most prevalent. LCA revealed different patterns of substance use by gender. Four- and two-class solutions best fitted the data for men and women, respectively. Aggressiveness and depression were associated with high depressant use membership for men. Among women, aggressiveness and anxiety symptoms were positively associated with high polydrug use membership. ConclusionsThe prevalent and patterned use of substances inside Spanish prisons and their association with aggressiveness and depression elevates the risk of harm during incarceration. In the interest of safety and wellness, correctional behavioral health services should include and expand the availability of gender-specific integrated mental health and substance use interventions that address maladaptive behaviors such as aggression.

A Tale of Two Jails: Leveraging Electronic Consultation to Address the Specialty Care Needs of the Vulnerable County Jail Population

Summary The Inland Empire Health Plan (IEHP), located in San Bernardino County, California — one of the largest not-for-profit Medicare-Medicaid plans in the United States — implemented an eConsult (electronic consultation) program in 2018 to improve care coordination and facilitate timely access to specialty care for all IEHP members. The program was soon expanded to include incarcerated individuals in two southern California county jail systems: Riverside County Correctional Health Services and the San Bernardino County Sheriff’s Department. The health plan’s Multi-County eConsult Initiative enabled primary care physicians (PCPs) serving the jail systems to consult promptly with specialists at regional health centers regarding care issues for inmates and to determine whether in-person referrals to specialists were warranted. IEHP’s review of eConsult’s impact on the care of inmates at these jails showed that over a 12-month period, 20% of all cases typically referred for in-person specialist visits were deemed unnecessary and were instead treated onsite by PCPs after consultation with the specialists. With this approach, access to specialists was more timely, efficient, and cost effective.

Patterns and Predictors of Reincarceration among Prisoners with Serious Mental Illness: A Cohort Study: Modèles et prédicteurs de réincarcération chez les prisonniers souffrant de maladie mentale grave : Une étude de cohorte.

A small proportion of people who have serious mental illness and rapid and frequent incarcerations account for a disproportionate amount of overall service use and cost. It is important to describe such individuals, so that services can respond more effectively. We investigated a cohort of 4,704 incarcerated men and women who were discharged from a correctional mental health service and followed for a median of 535 days. We investigated social, clinical, demographic, and offense characteristics as predictors of return to the service using Cox survival analyses. Secondly, we characterized individuals as high-frequency service users as those who had 3 or more incarcerations during a 1-year period and investigated their characteristics. We found that a higher rate of return to custody was associated with schizophrenia spectrum/bipolar affective disorder (BPAD), personality disorder traits, crack cocaine and methamphetamine use, and unstable housing. Charges of theft/robbery and breach of probation were also positively associated, and sex assault was negatively associated with return to custody. Within a 1-year time period, we found 7.2% of individuals were high-frequency service users, which accounted for 19.5% of all reincarcerations. Identification of the characteristics of those with mental illness in custody, especially those who have high-frequency returns to custody, may provide opportunity to target resources more effectively. The primary targets of intervention would be to treat those with schizophrenia/BPAD and substance use problems, particularly those using stimulants, and addressing homelessness. This could reduce the problem of repeated criminalization of the mentally ill and reduce the overall incarceration rate.

Learning from New York City Health + Hospitals' Experience with COVID-19

Health SecurityVol. 18, No. 5 Special Feature: NYC Health+Hospitals COVID-19 ResponseFree AccessLearning from New York City Health + Hospitals' Experience with COVID-19Eric TonerEric TonerAddress correspondence to: Eric Toner, MD, Johns Hopkins Center for Health Security, 621 East Pratt St, Suite 210, Baltimore, MD 21202 E-mail Address: Email:E-mail Address: etoner1@jhu.eduEric Toner, MD, is a Senior Scholar, Johns Hopkins Center for Health Security, and a Senior Scientist, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health; both in Baltimore, MD.Search for more papers by this authorPublished Online:12 Oct 2020https://doi.org/10.1089/hs.2020.0143AboutSectionsView articleView PDFView PDF Plus ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleIn this special feature of Health Security, we present a compendium of 7 commentaries by authors from New York City Health + Hospitals (NYC H+H) describing their experience with the first surge of novel coronavirus 2019 (COVID-19) cases to hit the United States. NYC H + H is the nation's largest municipal health system, with over 40,000 employees providing care in 11 acute care hospitals, 5 post-acute care facilities, many ambulatory care centers, and correctional health services. During March and April 2020, New York City was the epicenter of the COVID-19 pandemic in the United States. With a peak of nearly 11,000 new confirmed cases per day on April 9, it bore the brunt of the US pandemic response. These commentaries illustrate and document the many lessons learned during this arduous and, at times, desperate effort to save lives and maintain a functioning health system.We have worked with NYC H + H to release these valuable commentaries quickly while we are still in the midst of the pandemic, so that other cities and hospitals in the United States and elsewhere can learn from NYC H+H's hard-learned lessons. The commentaries cover activities from a wide spectrum of departments, programs, and activities within the health system, including the emergency department, special pathogen program, quality and wellness offices, palliative care, emergency management, and community care division. The commentaries describe many innovative projects, such as using isolation hotels, working with the military to combat acute psychological stress in healthcare workers, and providing palliative care remotely.New York City has been challenged many times in recent years (eg, 9/11, Hurricane Sandy), but never before has the healthcare system been so profoundly tested. We applaud the valiant and often heroic efforts of the New York City healthcare workers during this pandemic. It is our hope that by providing this rapid-cycle special feature we can give our readers valuable insights into how to better prepare their own hospital, city, or organization for the COVID-19 pandemic and future health crises.FiguresReferencesRelatedDetails Volume 18Issue 5Oct 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Eric Toner.Health Security.Oct 2020.349-349.http://doi.org/10.1089/hs.2020.0143Published in Volume: 18 Issue 5: October 12, 2020KeywordsCOVID-19New York CityPublic health preparedness/response

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Improving Care at Correctional Facilities: Listening, Learning and Creating Change from a Patient Care Quality Office.

Correctional Health Services (CHS) became part of the Provincial Health Services Authority in British Columbia (BC) in October, 2017. There are 2,700 clients in BC in 10 facilities, and approximately 60% of these clients have mental health issues and/or substance use issues. To address healthcare quality complaints and queries for this unique setting, in keeping with provincial legislation, nursing role of the patient care quality specialist was created in 2018. Challenges, particularly related to direct communication limitations due to the security of incarcerated persons, have led to adapted processes, tools and approaches. Numerous collaborations have been established within and external to the CHS in BC, including the Federal Correctional Services and Accreditation Canada, which have resulted in new relationships to better understand client issues, develop policies and support continuity of care between the community and the correctional facility.

“I Just Had No Idea What It Was Like to Be in Prison and What Might Be Helpful”: Educator and Learner Views on Clinical Placements in Correctional Health

Phenomenon: Correctional health services can provide quality learning experiences for medical students and graduate medical trainees, including through motivating learners to work with people involved with the justice system, and promoting understanding of the social determinants of health. Approach: We conducted 38 semi-structured interviews to examine the views of learners and educators on how to promote high quality clinical learning in correctional settings, with a focus on the Australian context. Participants included medical students; general practitioners who had undertaken graduate trainee placements; clinical staff involved in teaching and clinical supervision; and graduate program medical educators and university teachers from Australia, New Zealand, and Canada. Data were analyzed thematically. Findings: Clinical placements in correctional settings provided learning about the health of people involved in the justice system, but also beneficial clinical learning for working with a wide range of patients with complex health needs. Valued learnings included managing complex consultations, mental health and substance use disorders, and overcoming anxiety related to interacting with people in prison. Learner concerns included limited patient contact time, apprehension prior to placements, and stress related to experiences during the placements. This apprehension and stress could be mitigated by orientation and debriefing, and by appreciating healthcare professionals in correctional settings as advocates for their patients. Clinical supervision was perceived to be demanding in this context. Independent patient interaction was not usually possible for students and there could be short windows of time in which to provide direct patient care, making pauses for teaching difficult. Insights: Clinical placements in correctional health services provide experiential learning of direct relevance to medical student, and potentially to general practice trainee, curricula which is valuable even when learners do not have particular interest in correctional health. Furthermore, these placements may increase the capacity of the medical workforce to provide skilled care to other underserved populations. High quality learner and clinical supervisor experiences, and program scale and sustainability, require enhanced learning support systems through partnerships between correctional health services and education institutions. Required supports for learners include orientation to security arrangements, debriefing sessions which assist learners to distill their learning and to reflect on challenging experiences, and alternative learning opportunities for when direct patient consultations are not accessible. Supervisor teaching supports include shared teaching approaches in the correctional health clinics and added student support from university-based staff.

Clinical Outcomes of Specialized Treatment Units for Patients With Serious Mental Illness in the New York City Jail System.

New York City's (NYC) Correctional Health Services has introduced specialized treatment units for patients with serious mental illness in the NYC jail system. With multidisciplinary mental health staffing and a coordinated approach with NYC's Department of Correction, these units expand therapeutic options for patients vulnerable to clinical instability and physical harm, including those at high risk of psychiatric medication nonadherence and those returning to jail from psychiatric hospitalization. This study evaluated the extent to which these units improve clinical outcomes for this population. This retrospective, observational cohort study included adult males with serious mental illness with a length of jail stay of ≥14 days between January 1, 2016, and March 31, 2018. Patients on treatment units were matched with patients of similar characteristics (control group) by using propensity score matching (N=302 pairs). Rates of self-injury, injury due to violence, and psychiatric medication adherence were analyzed. Most patients on treatment units had diagnoses of schizophrenia spectrum and other psychotic disorders (81%), and most had a violent felony as their most severe charge (68%). Compared with patients in a control group, those on the treatment units had lower rates per 100 person-days of injury due to violence at 30 and 60 days (0.04, 95% confidence interval [CI]=0.02-0.07, and 0.03, 95% CI=0.02-0.06, respectively) and higher mean medication adherence (77% versus 55%, p<0.001). They also experienced lower rates of self-injury, although the difference was not statistically significant. Initial outcomes indicate substantial benefits to patients, demonstrating the value of a rehabilitative approach to psychiatric care in jail.

The Harms of a Penal Colony.

More than just a jail, Rikers has become a site of shifting discourse on punishment and justice in the United States. In the book Life and Death in Rikers Island, Homer Venters argues that the systematic failures of jails to provide appropriate safety and care constitute human rights violations and public health risks. The former chief medical officer and commissioner of correctional health services for the NYC Health and Hospitals system, Venters offers critical insight on the Rikers jail system. "Because jails are chaotic and concealed from outside view," he asserts, "we only become aware of them when very bad outcomes occur, such as deaths." Life and Death's success lies in how it blends Venters's experiences on the ground as a health care professional with the empirical data he's been able to collect and analyze over the tenure of his career. According to Venters, all suicides, homicides, and accidental deaths in jail are jail attributable, as they reflect system-wide failures in safety.

Adaptation of an Evidence-Based Intervention to Reduce HIV Risk in an Underserved Population: Young Minority Men in New York City Jails.

To address HIV-risk among justice-involved minority men, New York City Health + Hospitals Correctional Health Services implemented a modified version of Choosing Life: Empowerment, Action Results (CLEAR), an evidence-based intervention to influence behavior. A total of 166 young (i.e., 20-29 years old) minority (e.g., non-Hispanic Black or Latinx) men at risk for HIV and incarcerated in New York City jails completed the adapted group-format intervention and corresponding evaluation assessments. Participants showed significantly improved HIV knowledge on the 18-item HIV-KQ-18 scale (mean increase = 3.11 correct, from 13.23 [SD = 3.80] pre-intervention to 16.34 [SD = 2.29] post-intervention). Similarly, participant summary scores for substance use risk, sexual risk, and health promotion improved significantly. At 90 days after jail release, participants reported improved "CLEAR thinking," reduced risk behaviors and improved health-promoting behaviors. Health and HIV-prevention education programs implemented in the jail setting may help reduce health inequities and improve health outcomes.