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LETTER |
Janet Myers is with the Center for AIDS Prevention Studies, University of California, San Francisco, and is a regular evaluation collaborator with Centerforce. Barry Zack is with Centerforce, San Rafael, Calif.
Correspondence: Requests for reprints should be sent to Janet Myers, PhD, MPH, University of California, San Francisco, Center for AIDS Prevention Studies, 50 Beale St, Suite 1300, San Francisco, CA 94105 (e-mail: janet.myers{at}ucsf.edu).
We appreciate Cohen and colleagues’ comments on our report of evaluation results from a prevention case management program (PCM) delivered to men and women leaving correctional settings in California ("Get Connected"). Cohen et al. argue that PCM "should not be touted as a cost-effective use of resources for HIV prevention"1(p400) and that other interventions may prevent HIV infections at a lower cost. We would like to point out that while cost-effectiveness analysis is a powerful tool for understanding the relative value of interventions, it requires incorporation of accurate inputs and assumptions. Cohen et al.’s analysis does not adequately reflect the characteristics of the population at hand, nor does it quantify the full range of PCM’s benefits. Furthermore, it is true that PCM requires significant resources, but results from "Get Connected" support its use with populations such as the one we serve for reasons beyond cost per HIV case averted.
Most Get Connected clients were African American or Latino and all had histories of incarceration. Cohen et al. likely underestimate the scope of HIV infection in this population because prevalence is higher in prison and in communities of color than in the general population.2,3 Risky behavior among inmates may also contribute to higher transmission rates among prisoners and former prisoners and their sexual and drug-using partners.4–6
Cohen et al’s analysis does not account for morbidity and mortality averted from causes other than HIV, which is likely significant.7 The intent of the initiative that funded Get Connected was to develop "comprehensive surveillance, prevention and health care activities for HIV, sexually transmitted diseases, tuberculosis, substance abuse, and hepatitis" (Centers for Disease Control and Prevention, unpublished grant application guidance). HIV risk behavior was just one of the outcomes we sought to influence with PCM. We were not able to collect clinical indicators as part of the evaluation, but the reduction in risk behavior we documented among clients likely resulted in lower rates of other undesirable outcomes.
Finally, the community-based organization in which this work took place, Centerforce, is guided by its mission "to strengthen individuals and families affected by incarceration through a comprehensive system of education and support."8 PCM is an approach that works well in the context of Centerforce because PCM and successful programs for individuals leaving prison share many of the same components.9 Any evaluation of the value of PCM must consider both HIV-related and non–HIV-related benefits, including intensive case management’s link to reduced rates of reincarceration and the cost savings associated with this reduction.10–11
References
1. Cohen D, Wu S.-Y., Farley T. HIV prevention case management is not cost-effective. Am J Public Health. 2006;96:400–401.
2. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health. 2002;92(11):1789–1794.
3. Ruiz JD, Molitor F, Sun RK, et al. Prevalence and correlates of hepatitis C virus infection among inmates entering the California correctional system. West J Med. 1999:170(3):156–160.[ISI][Medline]
4. Krebs CP. High-risk HIV transmission behavior in prison and the prison subculture. Prison J. 2002;82(1): 19–49.
5. Swartz JE, Lurigio AJ, Weiner DA. Correlates of HIV risk behavior among prison inmates: implications for tailored AIDS prevention programming. Prison J. 2004;84(4):486–504.[CrossRef]
6. Martin SS, O’Connell DJ, Inciardi JA, Surratt HL, Beard RA. HIV/AIDS among probationers: an assessment of risk and results from a brief intervention. J Psychoactive Drugs. 2003;35(4):435–443.[ISI][Medline]
7. Ruiz JD, Molitor F, McFarland W, et al. Prevalence of HIV infection, sexually transmitted diseases and hepatitis and related risk behavior in young women living in low-income neighborhoods of northern California. West J Med. 2000;172:368–373.[CrossRef][ISI][Medline]
8. Centerforce Mission Statement. Available at: http://www.centerforce.org/AboutUs. Accessed December 26, 2005.
9. Centers for Disease Control and Prevention. HIV prevention case management: guidance. September 1997. Available at: http://www.cdc.gov/hiv/pubs/hivpcmg.htm. Accessed July 11, 2005.
10. Petersilia J. What works in prisoner reentry? Reviewing and questioning the evidence. Federal Probation. 2004;68. Available at: http://www.uscourts.gov/fedprob/September_2004/whatworks.html. Accessed December 26, 2005.
11. Centerforce. Successful Community Reentry Programs [fact sheet]. June 2005.
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