Health & Justice
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Open Access journal
ISSN (Print) 2194-7899
Published by SpringerOpen [188 journals]
- Integrated multisystem analysis in a mental health and criminal justice
Abstract: Background Patients with a serious mental illness often receive care that is fragmented due to reduced availability of or access to resources, and inadequate, discontinuous, and uncoordinated care across health, social services, and criminal justice organizations. This article describes the creation of a multisystem analysis that derives insights from an integrated dataset including patient access to case management services, medical services, and interactions with the criminal justice system. Methods Data were combined from electronic systems within a US mental health ecosystem that included mental health and substance abuse services, as well as data from the criminal justice system. Cox models were applied to test the associations between delivery of services and re-incarceration. Additionally, machine learning was used to train and validate a predictive model to examine effects of non-modifiable risk factors (age, past arrests, mental health diagnosis) and modifiable risk factors (outpatient, medical and case management services, and use of a jail diversion program) on re-arrest outcome. Results An association was found between past arrests and admission to crisis stabilization services in this population (N = 10,307). Delivery of case management or medical services provided after release from jail was associated with a reduced risk for re-arrest. Predictive models linked non-modifiable and modifiable risk factors and outcomes and predicted the probability of re-arrests with fair accuracy (area under the receiver operating characteristic curve of 0.67). Conclusions By modeling the complex interactions between risk factors, service delivery, and outcomes, systems of care might be better enabled to meet patient needs and improve outcomes.
- Acceptability and effectiveness of a web-based psychosocial intervention
among criminal justice involved adults
Abstract: Background The acceptability, feasibility and effectiveness of web-based interventions among criminal justice involved populations are understudied. This study is a secondary analysis of baseline characteristics associated with criminal justice system (CJS) status as treatment outcome moderators among participants enrolling in a large randomized trial of a web-based psychosocial intervention (Therapeutic Education System [TES]) as part of outpatient addiction treatment. Methods We compared demographic and clinical characteristics, TES participation rates, and the trial’s two co-primary outcomes, end of treatment abstinence and treatment retention, by self-reported CJS status at baseline: 1) CJS-mandated to community treatment (CJS-mandated), 2) CJS-recommended to treatment (CJS-recommended), 3) no CJS treatment mandate (CJS-none). Results CJS-mandated (n = 107) and CJS-recommended (n = 69) participants differed from CJS-none (n = 331) at baseline: CJS-mandated were significantly more likely to be male, uninsured, report cannabis as the primary drug problem, report fewer days of drug use at baseline, screen negative for depression, and score lower for psychological distress and higher on physical health status; CJS-recommended were younger, more likely single, less likely to report no regular Internet use, and to report cannabis as the primary drug problem. Both CJS-involved (CJS -recommended and -mandated) groups were more likely to have been recently incarcerated. Among participants randomized to the TES arm, module completion was similar across the CJS subgroups. A three-way interaction of treatment, baseline abstinence and CJS status showed no associations with the study’s primary abstinence outcome. Conclusions Overall, CJS-involved participants in this study tended to be young, male, and in treatment for a primary cannabis problem. The feasibility and effectiveness of the web-based psychosocial intervention, TES, did not vary by CJS-mandated or CJS-recommended participants compared to CJS-none. Web-based counseling interventions may be effective interventions as US public safety policies begin to emphasize supervised community drug treatment over incarceration.
- Commentary: the importance of Medicaid expansion for criminal justice
populations in the south
Abstract: Abstract Though the full implications of a Trump presidency for ongoing health care and criminal justice reform efforts remain uncertain, whatever policy changes are made will be particularly salient for the South, which experiences the highest incarceration rates, highest uninsured rates, and worst health outcomes in the United States. The passage of the Affordable Care Act (ACA) in 2010 was a watershed event and many states have taken advantage of opportunities created by the ACA to expand healthcare coverage to their poorest residents, and to develop partnerships between health and justice systems. Yet to date, only four have taken advantage of the benefits of healthcare reform. Expanding Medicaid would provide Southern states with the opportunity to significantly impact health outcomes for criminal justice-involved individuals. In the context of an uncertain policy landscape, we suggest the use of three strategies, focusing on advancing incremental change while safeguarding existing gains, rebranding Medicaid as a local or statewide initiative, and linking Medicaid expansion to criminal justice reform, in order to implement Medicaid expansion across the South.
- Extending smoking abstinence after release from smoke-free prisons:
protocol for a randomised controlled trial
Abstract: Background A smoking ban was implemented across all prisons in Queensland, Australia, in May 2014, with the aim of improving the health of prisoners and prison staff. However, relapse to smoking after release from prison is common. Only one previous study, conducted in the United States, has used a randomised design to evaluate an intervention to assist individuals in remaining abstinent from smoking following release from a smoke-free prison. Methods This paper describes the rationale for and design of a randomised controlled trial of an intervention to extend smoking abstinence in men after release from smoke-free prisons in the state of Queensland, Australia. Participants in the intervention group will receive a brief intervention involving four group sessions of motivational interviewing and cognitive behavioural therapy, initiated 4 weeks prior to release from prison. The comparison group will receive a pamphlet and brief verbal intervention at the time of baseline assessment. Assessment of self-reported, post-release smoking status will be conducted by parole officers at regular parole meetings with the primary outcome measured at 1 month post release. Discussion The prevalence of smoking and related health harms among people who experience incarceration is extremely high. Effective interventions that result in long-term smoking cessation are needed to reduce existing health disparities in this vulnerable population. Trial registration Current Controlled Trials ACTRN12616000314426
- Characteristics of expert opinions on insanity accepted by NZ Courts
Abstract: Background Health and justice have to communicate whenever the question of legal responsibility is raised with respect to a person accused of a serious crime. Both recommendations and practices on expert report design and content vary widely. Methods This paper briefly reviews the characteristics of 27 reports accepted as persuasive in contested New Zealand cases. Results and conclusions Relative brevity, presenting the opinions within a court friendly structure, and emphasising the information available around the time of the events, as opposed to information clinically or legally reconstructed, all appear to be important.
- Are Australian prisons meeting the needs of Indigenous offenders?
Abstract: Background The over-representation of Indigenous Australians in custody is well documented, yet little is known about whether the health and social needs of Indigenous prisoners are met in correctional facilities. This study sought to identify common areas of need in a representative sample of Indigenous people in custody, and consider how well prison services were addressing these issues. Methods The sample comprised 122 Aboriginal and Torres Strait Islander people in custody in Victoria. Participants were administered the Camberwell Assessment of Need Forensic-Short Version to ascertain the presence or absence of needs in custody. Statistical analyses to determine associations with re-offence were conducted. Results Findings indicated that prisons were able to meet the non-criminogenic needs of many offenders; however there was a limited capacity to address specific criminogenic needs. Psychological distress, substance abuse, poor treatment adherence and threatening behaviours were considered ongoing needs regardless of supports/interventions being provided. Moreover, these four unaddressed needs were all associated with future recidivism. Conclusions Effective prison treatment services focusing on these four areas of need are urgently required. Such initiatives require continuation post-release combined with additional assistance to uphold basic non-criminogenic needs acquired in prison.
- Substance use disorders among Aboriginal and Torres Strait Islander people
in custody: a public health opportunity
Abstract: Background To describe the prevalence, type, and mental health correlates of substance use disorders in a large sample of incarcerated Indigenous Australians. Methods An epidemiological survey of the mental health of Indigenous people in custody in the state of Queensland, Australia was conducted using culturally informed methods. The prevalence, type and mental health correlates of substance use disorders were determined using a diagnostic interview and questionnaire. Results In a sample of 396 Indigenous people (331 males, 65 females) the prevalence of any substance use disorder was 66%. Alcohol dependence (males 47%, females 55%) was the most common type of substance use disorder, followed by cannabis dependence (males 20%, females 26%). Mental illness (anxiety, depression and psychotic disorder), and lifetime suicide thoughts and attempts, were significantly more likely among those with a substance use disorder. The majority of the sample reported intoxication with alcohol (70%) and/or other drugs (51%) at the time of arrest. Most individuals (87%) had not accessed alcohol and other drug services in the 12 months prior to custody. Conclusions Substance dependence was common in this sample and was associated with other forms of mental health adversity, yet most individuals reported no access to health services prior to incarceration. Effectively responding to substance dependence for Indigenous Australians is a public health and criminal justice priority. Culturally capable alcohol and other drug treatment services in custody and in the community are critical, and should be co-located and coordinated with mental health services.
- Agreement between self-reported healthcare service use and administrative
records in a longitudinal study of adults recently released from prison
Abstract: Background Studies of healthcare service use often rely on self-reported data, especially in disadvantaged populations. Despite this, the reliability of self-reported healthcare service use is often questioned and routinely-collected, administrative data are usually considered preferable. In this paper we examine the agreement between self-reported healthcare service use and administrative records, in a large cohort of adults recently released from prison in Australia. Methods Baseline interviews within 6 weeks of expected release from prison and follow-up interviews at 1, 3 and 6 months post-release were linked to routinely-collected, administrative health records over the same time period. Outcomes of interest included use of primary care, emergency department presentation, hospitalisation and dispensing of subsidised pharmaceuticals. Kappa statistics and positive and negative predictive values were calculated for each service type and time point, and a modified Poisson regression was used to identify participant characteristics associated with better agreement. Results 864 participants completed interviews and were successfully linked to administrative records. There was good agreement between self-report and administrative health records. Agreement between data sources at 1 month was best for psychotropic medications (kappa = 0.79) and primary care visits (kappa = 0.69). Conclusion Despite a common perception that studies using self-reported data are subject to bias, particularly among the disadvantaged, our findings suggest that self-reported healthcare may be valid in vulnerable populations.
- Interventions for drug-using offenders with co-occurring mental health
problems: a systematic review and economic appraisal
Abstract: Background Drug-using offenders with co-occurring mental health problems are common in the criminal justice system. A combination of drug use and mental health problems makes people more likely to be arrested for criminal involvement after release compared to offenders without a mental health problem. Previous research has evaluated interventions aimed broadly at those with a drug problem but rarely with drug use and mental health problems. This systematic review considers the effectiveness of interventions for drug-using offenders with co-occurring mental health problems. Methods We searched 14 electronic bibliographic databases up to May 2014 and five Internet resources. The review included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and/or criminal activity. Data were reported on drug and crime outcomes, the identification of mental health problems, diagnoses and resource information using the Drummond checklist. The systematic review used standard methodological procedures as prescribed by the Cochrane collaboration. Results Eight trials with 2058 participants met the inclusion criteria. These evaluated: case management (RR, 1.05, 95 % CI 0.90 to 1.22, 235 participants), motivational interviewing and cognitive skills, (MD-7.42, 95 % CI-0.20.12 to 5.28, 162 participants) and interpersonal psychotherapy (RR 0.67, 95 % CI 0.3 to 1.5, 38 participants). None of these trials reported significant reductions in self-report drug misuse or crime. Four trials evaluating differing therapeutic community models showed reductions in re-incarceration (RR 0.28, 95 % CI 0.13 to 0.63, 139 participants) but not re-arrest (RR 1.65, 95 % CI 0.83 to 3.28, 370 participants) or self-report drug use (RR 0.73, 95 % CI 0.53 to 1.01, 370 participants). Mental health problems were identified across the eight trials and 17 different diagnoses were described. Two trials reported some resource information suggesting a cost-beneficial saving when comparing therapeutic communities to a prison alternative. Conclusions Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. Specifically, tailored interventions are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.
- Unlocking dimensions of social capital in the prison setting
Abstract: Background Social capital has been shown to be a valuable resource for improving health outcomes. However, it has received little attention in the prison setting. Dimensions of social capital in mainstream society are likely to function differently among inmates in prison. This study seeks to identify and understand social capital dimensions among incarcerated men living with hepatitis C. Methods In-depth interviews were conducted across three correctional centres in New South Wales with 30 male inmates living with hepatitis C. Interviews were transcribed then thematically coded and analysed. Results There were differences in the access and utility of social capital dimensions in prison focusing specifically on trust and safety, informal and formal networks, agency, and civic engagement. Conclusions Dimensions of social capital do not necessarily translate into prison. An inmate’s social capital may foster greater treatment uptake relating to health and rehabilitative programs during their incarceration.
- Alcohol management plans in Indigenous communities in Queensland
(Australia) may have unintended implications for the care of children
Abstract: Background Indigenous children in Australia are more likely than non-Indigenous children to be in contact with the child safety system. A large number of Queensland’s Indigenous population live in remote and isolated communities in north Queensland where the state government's Alcohol Management Plans (AMPs) are in effect. In these communities it is an offence to have in one’s possession more than the regulated amount and type of alcohol. A breach of these restrictions can result in convictions under the Liquor Act 1992. Findings During an evaluation of AMPs, influential stakeholders and key service providers voiced their belief that a conviction for a breach of the AMP would impact a person’s eligibility to hold a Positive Notice Blue Card (PNBC). On its own, however, a breach of the Liquor Act 1992 will not impact a person’s eligibility for a PNBC. A PNBC is required for any person volunteering or working with children. Without a PNBC, a person is ineligible to work in child-related employment, volunteer at child-related activities or provide out-of-home care for children. Conclusion This misconception needs to be addressed in these already-disadvantaged communities to ensure that Indigenous community members have every opportunity to hold a PNBC. Focused strategies with evaluation and research are needed in this important policy area.
- The effectiveness of specialized legal counsel and case management
services for indigent offenders with mental illness
Abstract: Background In recent years, jurisdictions have recognized the strain placed on limited existing resources by criminal offenders with mental illness who frequently cycle through local jail facilities. In response, many locales have developed and implemented specialized programs to more effectively and efficiently manage these offenders, particularly the process of assigning defense attorneys to these often indigent defendants. Methods The current study examined the impact of an Indigent Defense Counsel (IDC) program designed to provide specially trained defense attorneys, and enhanced case management services to 257 indigent jail inmates with a qualifying, major mental health diagnosis (e.g., major depression). These offenders were compared to 117 similar offenders who did not receive these services, on both their length of stay in the jail, and their likelihood of recidivism after release to the community. Results Survival analyses revealed that program participants spent about 17 fewer days in jail; however, recidivism rates between groups, measured as return to the same county jail or as statewide re-arrest, did not differ. Conclusions These results suggest that defendants with mental illness can potentially be managed effectively in the community, with little added risk to public safety and at potential savings in jail bed days/costs. Implications for the processing of indigent criminal defendants with mental illness are presented.
- Gender and race disparities in weight gain among offenders prescribed
antidepressant and antipsychotic medications
Abstract: Background Studies have found that antipsychotics and antidepressants are associated with weight gain and obesity, particularly among women and some minority groups. Incarcerated populations (also referred to as offenders, prisoners or inmates) have a high prevalence of mental health problems and 15 % of offenders have been prescribed medications. Despite rates of antidepressant and antipsychotic use, investigations of weight gain and obesity in regard to these agents seldom have included offenders. Methods This retrospective descriptive study (2005–2011) was conducted with a Department of Corrections in the east south central United States to investigate the relationship between antidepressant and antipsychotic agents, weight gain, obesity and race or gender differences. We sampled adult offenders who had an active record, at least two weight observations and height data. Offenders were classified into one of four mutually exclusive groups depending upon the type of medication they were prescribed: antidepressants, antipsychotics, other medications or no pharmacotherapy. Results The sample population for this study was 2728, which was 25.2 % of the total population. The population not on pharmacotherapy had the lowest baseline obesity rate (31.7 %) compared to offenders prescribed antipsychotics (43.6 %), antidepressants (43.6 %) or other medications (45.1 %). Offenders who were prescribed antidepressants or antipsychotics gained weight that was significantly different from zero, p < .001 and p = .019, respectively. Women in the antidepressant group gained 6.4 kg compared to 2.0 kg for men, which was significant (p = .007). Although women in the antipsychotic group gained 8.8 kg compared to 1.6 kg for men, the finding was not significant (p = .122). Surprisingly, there were no significant differences in weight gain between African Americans and Whites in regard to antidepressants (p = .336) or antipsychotic agents (p = .335). Conclusion This study found that women and men offenders prescribed antidepressant or antipsychotic agents gained weight during their incarceration. Women prescribed antidepressants gained significantly more weight than men. However, there was no significant difference in weight gain between African Americans and Whites. Results suggest further investigation is needed to understand the effect of medication history, metabolic syndrome and to explain gender disparities.
- Exploring barriers to and enablers of adequate healthcare for Indigenous
Australian prisoners with cancer: a scoping review drawing on evidence
from Australia, Canada and the United States
Abstract: Background International frameworks supported by national principles in Australia stipulate that prisoners should be provided with health services equivalent to those provided in the general community. However, a number of barriers unique to the prison system may hinder the provision of equitable healthcare for this population. In Australia, Indigenous people carry a greater burden of cancer mortality, which the Cancer Data and Aboriginal Disparities (CanDAD) project is seeking to address. During the course of recruiting participants to the CanDAD study, Indigenous Australian prisoners with cancer emerged as an important, under-researched but difficult to access sub-group. Methods This scoping review sought to identify barriers and facilitators of access to adequate and equitable healthcare for Indigenous Australian prisoners with cancer in Australia. This review demonstrated a lack of research and, as such, the scoping review was extended to prisoners with cancer in Australia, New Zealand, the United States and Canada. This approach was taken in order to summarise the existing body of evidence regarding the barriers and facilitators of access to adequate and equitable healthcare for those who are incarcerated and suffering from cancer, and highlight areas that may require further investigation. Results Eight studies or commentaries were found to meet the inclusion criteria. This limited set of findings pointed to a range of possible barriers faced by prisoners with cancer, including a tension between the prisons’ concern with security versus the need for timely access to medical care. Conclusion Findings identified here offer potential starting points for research and policy development. Further research is needed to better elucidate how barriers to adequate cancer care for prisoners may be identified and overcome, in Australia and internationally. Furthermore, given Indigenous Australians’ over-burden of cancer mortality and over-representation in the prison system, further research is needed to identify whether there are a unique set of barriers for this group.
- Patients’ experiences managing cardiovascular disease and risk
factors in prison
Abstract: Background Despite greater risk of cardiovascular disease (CVD) mortality in patients with a history of incarceration, little is known about how prisons manage CVD risk factors (CVD-RF) to mitigate this risk. Methods We conducted in-depth interviews with individuals with CVD-RF who had been recently released from prison (n = 26). These individuals were recruited through community flyers and a primary care clinic in Connecticut. Using a grounded theory approach and the constant comparative method, we inductively generated themes about CVD-RF care in prisons. Data collection and analysis occurred iteratively to refine and unify emerging themes. Results Four themes emerged about care in prison: (1) Participants perceive that their CVD-RFs are managed through acute, rather than chronic, care processes; (2) Prison providers’ multiple correctional and medical roles can undermine patient-centered care; (3) Informal support systems can enhance CVD-RF self-management education and skills; and (4) The trade-off between prisoner security and patient autonomy influences opportunities for self-management. Conclusions Patients develop self-management skills through complex processes that may be compromised by the influence of correctional policies on medical care. Our findings support interventions to engage peers, medical providers, care delivery systems, and correctional staff in cultivating effective self-management strategies tailored to prison settings.
- From trauma to incarceration: exploring the trajectory in a qualitative
study in male prison inmates from north Queensland, Australia
Abstract: Background There were approximately 34,000 prisoners incarcerated in Australian correctional centres as of 2014. The most common offence type for these prisoners was ‘acts intended to cause injury’, comprising 18 % of the total offences. Of the various risk factors for violent offending and incarceration identified in international research, trauma - either single events or ongoing; and substance abuse - which is commonly associated with violent behaviour across many cultures, are major contributors. Method This paper analyses qualitative data from 11 in-depth interviews with inmates from a high security male correctional centre in QLD, Australia. The aim of the study was to explore risk factors for violence and incarceration for men from far north Queensland. Results A common trajectory to violent offending and incarceration was identified for these prisoners, including: childhood/adolescent trauma; a lack of support or treatment for trauma experiences; substance abuse to mask the pain; and a ‘brain snap’ precipitating a violent offence. Conclusion Further research is required into factors leading to violent offending and incarceration generally. In particular early detection and intervention for trauma victims is imperative in order to reduce exposure to such a harmful trajectory from trauma to incarceration.
- Social support quality and availability affects risk behaviors in
Abstract: Background People involved in the justice system are at 2.5 times the risk of HIV infection compared to the general population, which is further complicated by substance abuse. The purpose of this study was to evaluate the role of social network quality and quantity on unprotected sex, criminal risk, and substance use. Methods We used data from 330 drug-involved offenders. Structural equation modeling (SEM) was used to model and test path directionality and magnitude between the latent constructs of social support quality and quantity on risky behaviors. Results The SEM indicated the latent construct of social support quality was significantly associated with reduced sexual risk behavior (β = −0.27), criminal risk (β = −0.26), and reduced substance use (β = −0.33). Additionally, the proposed model found that social support quantity was significantly positively associated with increased sexual risk behavior (β = 0.40) and substance use (β = 0.20). Conclusions Social support quality is an important predictor of risky behaviors; as the quality of an offender’s social support increases, engagement in risky behaviors decreases. Probationers who had broader social support availability also had increased substance use and unprotected sex. Probation systems may be able to reduce substance use and STD/HIV infection risk in offenders by strengthening the quality of social support networks.
- “On papers”: perceptions of synthetic cannabinoid use among black
males under criminal justice supervision
Abstract: Background A number of studies reveal a strong linkage between SC use and avoiding positiveurine creens. Despite this work and given the high rates of criminal justice supervision among Black men in the U.S., little is known about SC usage among Black men under criminal justice supervision. Methods In-depth qualitative interviews were conducted with 11 Black men under criminal justicesupervision treated by an urban ED for violent injury. Results Themes that emerged from the analysis include 1) prevalence of use, 2)health literacy, 3) availability and costs, 4) negative side effects, and 5) criminal justice supervision. Conclusions Criminal justice supervision policies are a contributing factor to SC use among Black men under criminal justice supervision.
- “Our commonality is our past:” a qualitative analysis of re-entry
community health workers’ meaningful experiences
Abstract: Background Re-entry community health workers (CHWs) are individuals who connect diverse community residents at risk for chronic health issues such as Hepatitis C virus and cardiovascular disease with post-prison healthcare and re-entry services. While the utilization of CHWs has been documented in other marginalized populations, there is little knowledge surrounding the work of re-entry CHWs with individuals released from incarceration. Specifically, CHWs’ experiences and perceptions of the uniqueness of their efforts to link individuals to healthcare have not been documented systematically. This study explored what is meaningful to formerly incarcerated CHWs as they work with released individuals. Methods The authors conducted a qualitative thematic analysis of twelve meaningful experiences written by re-entry CHWs employed by the Transitions Clinic Network who attended a CHW training program during a conference in San Francisco, CA. Study participants were encouraged to recount meaningful CHW experiences and motivations for working with re-entry populations in a manner consistent with journal-based qualitative analysis techniques. Narratives were coded using an iterative process and subsequently organized according to themes in ATLAS.ti. Study personnel came to consensus with coding and major themes. Results The narratives highlighted thought processes and meaning related to re-entry CHWs’ work helping patients navigate complex social services for successful re-integration. Six major themes emerged from the analysis: advocacy and support, empathy relating to a personal history of incarceration, giving back, professional satisfaction and responsibilities, resiliency and educational advancement, and experiences of social inequities related to race. Re-entry CHWs described former incarceration, employment, and social justice as sources of meaning for assisting justice-involved individuals receive effective, efficient, and high-quality healthcare. Conclusions Health clinics for individuals released from incarceration provide a unique setting that links high risk patients to needed care and professionalizes career opportunities for formerly incarcerated re-entry CHWs. The commonality of past correctional involvement is a strong indicator of the meaning and perceived effectiveness re-entry CHWs find in working with individuals leaving prison. Expansion of reimbursable visits with re-entry CHWs in transitions clinics designed for re-entering individuals is worthy of further consideration.
- Effect of social relationships on antiretroviral medication adherence for
people living with HIV and substance use disorders and transitioning from
Abstract: Background This paper examines how family and social relations facilitate and inhibit adherence to antiretroviraltherapy (ART) for people living with HIV (PLH) who have underlying substance use disorders and are transitioningto the community post-incarceration. Methods Combining the methods of inductive close reading and constantcomparison, we analyzed the data from 30 semi-structured interviews of PLH who had recently transitioned to thecommunity within the previous 90 days. Results Three central themes were anticipated as important socialrelationships post-release: self-reported family, friends and clinicians. Among these, four sub-themes (social isolation, ‘double jeopardy’, search for belonging, and trust and respect) emerged, highlighting how they impacted ART adherence. Post-release, participants returned to resource-poor communities where they experienced socialisolation. ART adherence was enabled by having a purpose in life, which correlated with having robust family support structures. Many former prisoners felt that a chasm between them and their families existed, both because of HIV stigma and their addiction problems. In this context, relationships with untrustworthy friends from their druguse networks led to relapse of drug use and risky behaviors, jeopardizing participants’ ART adherence and persistence. To avoid the double jeopardy, defined as seeking friends for support but who were also the ones who contributed to drug relapse, participants searched for new social anchors, which often included their healthcare providers who represented trusted and respected persons in their life. Conclusions While some former prisonersperceived doctors as uncaring and their relationships asymmetrical, positive relationships with these providers,when respect and trust was mutual, reinforced the participants’ sense of belonging to what they called ‘the world that don’t do drugs’ and motivated them to adhere to ART.