A. Abstract One out of six people with HIV (PWH) in the U.S. are incarcerated annually; two-thirds of incarcerated persons meet criteria for substance use disorder (SUD) and many more in carceral settings are at risk for HIV. Ending the U.S. HIV epidemic hinges on linking and engaging criminal legal system-involved people with and at risk for HIV, especially those with SUDs, to optimize ART and PrEP uptake and adherence. Carceral facilities can offer ART and PrEP access, and increasingly SUD treatment, but in the year following release, nearly 80% of PWH lack viral suppression, and PrEP coverage is extremely limited. Post-release disruptions in ART stem from multiple causes: health system complexity, SUD relapse, unstable housing, medical mistrust, and stigma. PrEP outcomes are underexplored, but preliminary data suggest similar challenges. Because HIV transmission risk is high upon community re-entry, multimodal interventions among recently incarcerated people with and at risk for HIV are critical to ending the HIV epidemic. The goal of this phased R61/R33 proposal is to develop a Decentralized, Status neutral, Stakeholder-engaged, post-incarceration intervention for people with and at risk for HIV with SUD: The DEST2nation model. In addition to peer navigation, we will collaborate with carceral-focused community-based organizations to address competing priorities, such as unstable housing, lack of employment in culturally sensitive environments that mitigate stigma. Our specific aims are to: Aim 1 (R61 phase): Pilot and refine a package of decentralized strategies to address barriers impacting criminal legal system-involved people with HIV and those at risk. Aim 2: (R33 phase): Test the DEST2nation model (vs. SoC) in a multisite randomized control trial. Aim 3 (R33): Estimate the cost of implementing and sustaining DEST2nation, and assess its economic value, relative to SoC, from healthcare sector, state-policymaker, and societal perspectives.

Project Narrative HIV and substance use disorders are highly prevalent among people involved with the criminal legal system and multiple barriers complicate access to medical care in the period following incarceration. Interventions that address these barriers are critical to ending the HIV epidemic. The goal of this proposal is to evaluate a comprehensive, person-centered model of post-incarceration care for people with and at risk for HIV that uses peers with lived experience of incarceration to assist with linkage and engagement in medical care and substance use disorder treatment, community based- organization partnerships to meet unmet social needs, and decentralized medical care to address barriers to access.