New “HOPE” for HIV Prevention and Addiction Treatment in Prisons

The Eastern Europe and Central Asia region remains the only region where the HIV epidemic continues to grow, primarily due to unsafe opioid injection. Kyrgyzstan, a small country of about six million people, has some of the best prison HIV prevention and addiction treatment programs in both the region and the world.

In institutionalized settings like prisons, everyone sees what everyone else is doing. Many people in these settings say initiating addiction treatment can feel humiliating, as it is like admitting you are not strong enough to handle your addiction yourself. This can also be dangerous, as you may lose your social status and respect in the prison social hierarchy, with dire consequences for safety. In the words of one prisoner who spoke for most peers, “You cannot look at prison life with sober eyes.” That’s where our intervention, HOPE, may help to alleviate many of these issues.

HOPE is a mindfulness-based group intervention that trains participants in skills for coping with challenges, resolving conflicts, and finding goals and purpose in life. HOPE is delivered by a clinical psychologist and an outreach worker with personal lived experience in incarceration and addiction treatment. We co-developed the intervention with people with lived experience of incarceration in Kyrgyzstan, and it is specifically designed for people in prisons.

Unlike many previous interventions, which didn’t account for prison subculture and informal rules and hierarchies of the prison gang, HOPE taps into peer-to-peer support. Through the HOPE intervention, medications for opioid use disorder are reframed as one of many, non-mandatory choices individuals can consider helping take better care of their health and meet their goals.

Addiction treatment is among the topics covered by the intervention’s 13 weekly group sessions, but it is not the explicitly announced primary goal. Instead, addiction management often comes as a byproduct of learning coping strategies and other skills.

Our initial research shows HOPE helped 12% of participants initiate and retain opioid agonist therapy—medications to prevent withdrawal and reduce cravings for opioid drugs— during incarceration whereas no control participants started treatment. HOPE also improved participants’ life satisfaction and decreased depressive symptoms, with effects sustained for up to 12 months post-intervention and showed a signal of decreased risk of hazardous alcohol use. This suggests HOPE has potential to improve the uptake of opioid agonist therapy by people in prisons, and ultimately to reduce the risks of relapse to active injection drug use and of HIV infection.

Our R01 study tests the effectiveness of HOPE in a larger randomized controlled trial across four male prisons in Kyrgyzstan and explores how HOPE may be brought to scale. We aim to learn whether the use of HOPE can be economically effective and affordable in a low-resource setting.

While this R01 study is based in Kyrgyzstan, we plan to explore how HOPE may be brought to institutions in the Connecticut Department of Corrections.