Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE)

The overarching objective of this study is to determine the effectiveness of an evidence-based community response project using a stepped-wedge community randomized trial. Specifically, the investigators will test the effect of an intervention to reduce substance use and related harms among people re-entering the community from rural jails. This study will compare people in a re-entry health navigation intervention with a comparison group of people who will get overdose education in jail. Everyone will take part in follow-up surveys for up to 6 months after release. The intervention is a health navigation intervention designed to reduce SUD and increase engagement in the SUD care cascade; reduce vulnerability to HIV, STIs, and HCV and increase engagement in the HIV, STI, and HCV care cascades; and reduce vulnerability to overdose deaths among adults who use drugs and are leaving local jails. The intervention is based on enhancements to START, a CDC-recognized, evidence-based, individual-level intervention designed to reduce HIV/STI/HCV risk.

START core components: (1) Hold pre- and post-release program sessions with clients transitioning back to the community from a correctional setting; (2) Use a client-focused incremental risk reduction approach; (3) Use assessment & documentation tools to provide structure; (4) Hire program staff that are familiar with HIV/STIs/HCV prevention and with the specific needs of people being released; (5) Staff /client relationships must be maintained post-release; (6) Conduct enrollment and schedule two pre-release program sessions within 60 days of a client's release that: a. give HIV/STI/HCV information; b. review client's HIV/STI/HCV risk; c. identify transitional needs; d. develop a personalized risk reduction and transitional plan; e. make facilitated referrals; (7) Schedule four post-release sessions to review and update the risk reduction/transitional plan(s) and provide facilitated referrals; (8) Provide condoms at each post-release session; (9) Actively maintain contact with clients.

The investigators will modify START a priori as follows: 1) Though originally designed for young men, START has been successfully applied to women leaving correctional settings. The investigators will implement START with all genders; 2) START's post-release sessions primarily occurred in homes and community venues, such as restaurants. Staff who will deliver START will be stationed primarily within the local department of health (DOH); 3) To enhance START's impact on drug use and HIV/HCV-related harms (e.g., IDU frequency),the investigators will integrate the NIDA Standard HIV intervention into START, including rapid HIV and HCV antibody testing and counseling. The NIDA Standard has been demonstrated to reduce drug use frequency, high-risk injection practices, and sexual risk; 4) START was not designed to reduce overdoses. The investigators will integrate an interactive training with animated scenarios and narration on preventing, recognizing, and responding effectively to an opioid OD. Participants in the intervention group will receive naloxone (not all participants will get naloxone),either upon release or at their first post-release session. Interventionists will encompass OD in risk reduction motivational interviewing.

CARE2HOPE covers the following counties: Rowan, Bath, Morgan, Menifee, Elliott, Lee, Owsley, Wolfe, Perry, Letcher, Leslie, Knott. Research staff will recruit participants at jails serving the 12 CARE2HOPE counties; these jails are either located in CARE2HOPE counties or counties have contracts with them to incarcerate their residents. The intervention sessions and data collection will be delivered by research staff called "Re-entry Health Navigators" or "REHNs". Participants are assigned to one of the two groups by chance based on when they are released from jail and when their county is randomly chosen to start the project. In August 2019, the investigators randomized each of the 12 study counties to a start date. Four counties will be randomized to start the intervention each year. In each wave, four counties will be randomized to start 6 months of enrollment into a control condition, followed by 6 months of enrollment into the intervention condition, with follow-up data collection on both extending 6 months beyond enrollment. The investigators anticipate an average enrollment of 25 participants per county per quarter, with a total final sample size for the trial of 1200 (n=600 intervention, n=600 control). After a county has met its target enrollment in both conditions, the intervention and comparison activities will no longer be offered in that county.