A Community-Based Intervention to Increase HIV Pre-Exposure Prophylaxis Use among Individuals Receiving Re-Entry Services: Results from a Formative Evaluation
A formative evaluation of a community-based re-entry program in Dallas, Texas, revealed that while criminal-legal individuals face significant barriers like low perceived risk and mistrust, they remain open to PrEP discussions when interventions address social needs, correct misconceptions, and utilize culturally competent, non-judgmental messaging.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
For people leaving prison or jail, the first few months back in society are a time of intense survival. The immediate priorities are finding a place to sleep, securing a job, and reconnecting with family. In this scramble to rebuild a life, health often gets pushed to the back of the line. This is particularly true for HIV prevention. While a medication called pre-exposure prophylaxis, or PrEP, exists to stop the virus from taking hold in the body, many people who have been incarcerated do not know it exists, do not believe they need it, or face barriers that make getting it nearly impossible. The virus spreads at higher rates among people involved with the criminal legal system, yet the transition from confinement to freedom is often where the most critical gaps in care appear. To bridge this gap, researchers needed to understand not just the medical facts, but the human reality of the people they hoped to help. They needed to know what these individuals actually thought about HIV, what they feared, and how they would best receive information about protecting themselves.
A team of researchers from medical centers and a community organization in Dallas, Texas, set out to design a program that could help people re-entering society access PrEP. Before launching the program, they conducted a formative evaluation, which is essentially a deep-dive listening tour to shape the approach. They sat down with ten individuals who had recently been released from incarceration and six staff members who work with them daily. The goal was to explore what these people knew about HIV, what they believed about their own risk, and what obstacles stood in their way. The interviews were not a test, but a conversation, allowing the researchers to hear directly from the people who would eventually be the focus of the health coaching intervention.
The conversations revealed a complex picture of needs and misconceptions. The individuals interviewed faced a mountain of competing demands. Housing, food, and employment were urgent, often overwhelming any thought of preventive health. Many participants admitted they would only seek medical help if a problem became so severe it stopped them from functioning in their daily lives. Beyond these practical hurdles, there was a deep-seated misunderstanding about the virus itself. While everyone knew HIV was sexually transmitted, many held the belief that it was a disease that only affected gay men. This association created a blind spot; straight men, who might have engaged in risky behavior while in prison or who simply did not identify as gay, did not see themselves as vulnerable. Some participants were surprised to learn that HIV rates are actually higher in the incarcerated population than in the general public, and that transmission often happens through heterosexual contact.
Despite these gaps in knowledge and the heavy weight of other life struggles, the researchers found a surprising openness. When the topic of PrEP was introduced, most people were willing to listen. They did not reject the idea outright, even if they initially thought it was not for them. The barrier was not a refusal to protect themselves, but a lack of clear, trustworthy information. Participants expressed concerns about side effects, the cost of medication, and a general mistrust of the medical system and government health initiatives. They also noted that the digital world had moved on without them; many had been incarcerated for so long that they were unfamiliar with smartphones and online portals, which are now standard tools for making doctor appointments or managing prescriptions.
The study also highlighted the importance of who delivers the message. The people interviewed suggested that a health coach would need to be someone they could trust, someone who understood the unique challenges of re-entry. Some felt a coach with a similar background would be most effective, while others emphasized that the most important trait was simply being genuine and respectful. They offered specific advice on how to talk about the subject: use plain language, avoid sounding condescending, and be willing to use humor to break the ice. They suggested that myths about how the virus spreads—such as the idea that it can be caught from the air or that it only affects certain groups—needed to be addressed directly and clearly.
Armed with these insights, the research team refined their plan for the health coaching intervention. They decided to move away from strict medical checklists that might exclude people and instead focus on anyone interested in learning about PrEP. They adjusted their training to ensure coaches spoke in a casual, non-judgmental tone, using analogies that made sense in everyday life, such as comparing the use of protection to wearing a seatbelt. They also built in ways to protect privacy, acknowledging that the fear of being judged or having their status revealed was a powerful deterrent. The final approach was designed to meet people where they were, addressing their immediate social needs while gently weaving in the possibility of HIV prevention.
The findings suggest that ending the HIV epidemic among people leaving the criminal legal system requires more than just handing out medication. It requires a strategy that respects the reality of their lives, dismantles the stigma that labels the disease as something that only happens to others, and builds a bridge of trust between the community and the healthcare system. By listening to the people they aim to serve, the researchers found that the door to prevention is not locked; it is simply waiting for the right key, one that is forged from understanding, respect, and clear, honest communication.
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