Special Needs for HIV+ Incarcerated Populations
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Special Needs for HIV+ Incarcerated Populations

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This presentation was developed for use at the Virginia Department of Corrections Academy for Staff Development. The purpose is to support clinicians and health care providers in correctional ...

This presentation was developed for use at the Virginia Department of Corrections Academy for Staff Development. The purpose is to support clinicians and health care providers in correctional settings who provide care to Persons Living with HIV.

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  • Candidiasis (Thrush)This is a fungal infection that is normally seen in patients with CD4 counts in this range. It is treatable with antifungal medications. A trained provider can usually diagnose thrush with a visual examination.Kaposi’s Sarcoma (KS)KS is caused by Human Herpes Virus-8. Before the introduction of antiretroviral therapy, as many as 1 in 5 patients with AIDS had KS. It can cause lesions on the body and in the mouth. In addition, this virus can affect internal organs and disseminate to other parts of the body without any external signs. Treatment plans can include chemotherapy to shrink the lesions, as well as antiretroviral therapy to increase CD4 cell count. A diagnosis is typically made by inspecting a lesion and performing a direct biopsy on it.PnuemocystisJirovecii Pneumonia (PCP)PCP is a fungal infection and is the OI that most often causes death in patients with HIV. It is treatable with antibiotic therapy and close monitoring. If necessary, prophylaxis is available for patients who are at risk for PCP, but who are not ready to start antiretroviral medication. Diagnosing PCP usually involves a hospital stay to ensure proper testing and treatment without complications.Histoplasmosis and Coccidiodomycosis These are fungal infections that are found in many regions of the United States. They often present as severe, disseminated illnesses in patients with low CD4 counts. Diagnosis consists of blood tests and evaluation for possible exposures related to geographical areas. Progressive Multifocal Leukoencephalopathy (PML)PML is a severe neurological condition that is caused by the JC virus and typically occurs in patients with CD4 counts below 200. While there is no definitive treatment for this disease, it has been shown to be responsive to antiretroviral therapy. In some cases, the disease resolves without any treatment.
  • ToxoplasmosisToxoplasmosis is caused by the parasite Toxoplasma gondii that can cause encephalitis and neurological disease in patients with low CD4 counts. The parasite is carried by cats, birds, and other animals and is also found in soil contaminated by cat feces and in meat, particularly pork. Toxoplasmosis is treatable with aggressive therapy, and prophylaxis is recommended for patients with low CD4 counts (usually less than 200). CryptosporidiosisCryptosporidiosis is a diarrheal disease caused by the protozoa Cryptosporidium, and it can become chronic for people with low CD4 counts. Symptoms include abdominal cramps and severe chronic diarrhea. Infection with this parasite can occur through: swallowing water that has been contaminated with fecal material; eating uncooked food (like oysters) that are infected; or by person-to-person transmission, including exposure to feces during sexual contact. Treatment and antiretroviral therapy are important. Cryptococcal InfectionCryptococcal infection is caused by a fungus that typically enters the body through the lungs and can spread to the brain, causing cryptococcal meningitis. In some cases, it can also affect the skin, skeletal system, and urinary tract. This can be a very deadly infection if not caught and properly treated with antifungal medication. Although this infection is found primarily in the central nervous system, it can disseminate to other parts of the body, especially when a person has a CD4 count of less than 50. Cytomegalovirus (CMV)CMV is an extremely common virus that is present in all parts of the world. CMV can be transmitted by saliva, blood, semen and other bodily fluids. It can cause mild illnesses when first contracted and many people may never have symptoms. However, it does not leave the body when someone is infected with CMV. In patients with HIV and low CD4 counts it can cause infections in the eye and gastrointestinal system. MycobateriumAviam Complex (MAC)MAC is a type of bacteria that can be found in soil, water, and many places in the environment. These bacteria can cause disease in people with HIV and CD4 Counts less that 50. The bacteria can infect the lungs or the intestines, or in some cases, can become “disseminated”. This means that it can spread to the blood stream and other parts of the body. If this occurs, it can be a life threatening infection. If a persons CD4 count is below 50, then medications are available to prevent this infection from occurring.
  • Staff should use the following infection control guidelines when managing inmates:Use correctional standard precautions when in contact with any inmate’s blood or other potentially infectious materials, whether or not the inmate is known to have HIV infection.Use infection control practices in which non-disposable patient-care items are appropriately cleaned, disinfected, or sterilized, based on the use. Take measures to prevent cross-contamination during patient care (e.g., dialysis, vascular access, cauterizing, or dental procedures), in accordance with the Centers for Disease Control Guidelines on Hand Washing and Hospital Environmental Control.Use the appropriate airborne, droplet, and/or contact transmission precautions when indicated for inmates with HIV infection who have or may have acute secondary infections that are transmissible by respiratory contact, or by direct hand or skin-to-skin contact.

Special Needs for HIV+ Incarcerated Populations Presentation Transcript

  • 1. Special Needs for HIV+Incarcerated Populations
  • 2. Introductions• Introduce yourself – Name – Facility – Role in Corrections – Why you chose this course – One thing you hope to take away from today
  • 3. Icebreaker
  • 4. WHAT ARE THE DATA SAYING
  • 5. National Incarceration Data• The 2008 Bureau of Justice Statistics reported that in 2005 that 1,430,298 persons were incarcerated which was a 9.6% increase from the 2000 Census.1• Racial and ethnic minorities are incarcerated at a higher rate than whites in the United States, and they are disproportionately infected with HIV.21 Census of State and Federal Correctional Facilities, 2005. Bureau of Justice Statistics. October 2008.2 MMWR; Volume 60, Number 24. Centers for Disease Control and Prevention. June 24, 2011.
  • 6. One out of every …1 out of every 41 Blacks compared to 1 out of every 245 Whites1 out of every 21 Black Males compared to 1 out of every 136 White Males1 out of every 279 Black Females compared to 1 out of every 1064 White Females1 One in 100: Behind Bars in America. Pew Charitable Trusts – Public Safety Performance Project. February 2008
  • 7. Disparities in Incarceration• 1 in 30 men between the ages of 20 and 34 is behind bars, for black males in that age group the figure is 1 in 9.• More than 1 in 100 adults is now locked up in America.• Men still are roughly 10 times more likely to be in jail or prison than women.• For black women in their mid- to late-30s, the incarceration rate also has hit the 1-in-100 mark.One in 100: Behind Bars in America. Pew Charitable Trusts – Public Safety Performance Project. February 2008
  • 8. AIDS and Corrections• A total of 21, 987 inmates held in state or federal prison on December 31, 2008 were HIV positive or had confirmed AIDS.• This accounted for 1.5% of the custody population.• 2007 data showed that persons in prisons for 2.4 times more likely to be diagnosed with AIDS.HIV in Prisons 2007-2008, Bureau of Justice Statistics Bulletin. December 2009 (Revised 01-28-10).
  • 9. Virginia Incarceration Data• According to one expert with the Virginia ACLU, ―…since 2000, Virginia’s prison population has increased by 58%.‖1• In 2009, 4.5% of Medical Monitoring Project (MMP) interview participants reported that in the 12 months prior to the interview, they were put in jail, detention, or prison for longer than 24 hours.2• At the end of 2008 there were 433 HIV+ inmates held in the custody of Virginia Correctional Facilities (State and Federal).21 https://acluva.org/7468/take-a-closer-look-virginia%E2%80%99s-recidivism-rate-still-isn%E2%80%99t-great/2 2011 Virginia Epidemiological Profile, Virginia Department of Health. 2012.
  • 10. Scope of HIV in Virginia 1• 1 in 380 Virginians is known to be living with HIV.• Blacks are 9 times more likely to be living with HIV than Whites• For every 5 Virginians living with HIV, approximately: 4 are Men 3 are Black 2 are Men who have Sex with Men 2 are Ages 20 – 34 at Diagnosis1 http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/DAta/fact%20sheets/Scope%20of%20HIVAIDS%20in%20VA_2-10.pdf
  • 11. HIV and Corrections in Virginia• In 2008, Virginia had 433 confirmed HIV cases in the custody of state or federal prisons which accounted for 1.3% of the custody population.• Of the those inmates, 322 were male and 36 were female.• In 2007, there were 3 AIDS-related Deaths leading to a rate of 9 per 100,000 in Virginia Correctional SettingsHIV in Prisons 2007-2008, Bureau of Justice Statistics Bulletin. December 2009 (Revised 01-28-10).
  • 12. HIV Prevalence in Corrections• The prevalence of HIV infection in the United States prison population is more than three times higher than that of the general population.1• While numbers remain high for HIV prevalence in prisons, the data may underestimate both HIV prevalence and incidence due to existing stigma and fear, which leads to nondisclosure of HIV-positive status and places prisoners at elevated risk of infection.21Baillargeon, Jacques, et. al. Predictors of Reincarceration and Disease Progression Among Released HIV-InfectedInmates. AIDS Patient Care and STDS. Volume 24, Number 6, 2010.2GMHC. HIV in US Jails and Prisons. http://www.gmhc.org/files/editor/file/a_pa_prison_report0511(1).pdfAccessed on September 3, 2012.
  • 13. The Testing Gap By Request, Opt-In, Opt-Out• A study reported in the 2011 MMWR showed – By Request Testing yielded a rate of 1.8 new HIV diagnoses per year. – Opt-In Testing yielded a rate of 5.1 new diagnoses per year. – Opt-Out Testing yielded a rate of 7.6 new diagnoses per year.MMWR;. Volume 60, Number 24. Centers for Disease Control and Prevention. June 24, 2011.
  • 14. Discussion• What are the data telling us about the populations affected by HIV and Incarceration?• What are the likely opportunities for Corrections to support the eradication of HIV-related Morbidity and Mortality?• What do persons working Corrections need to know to contribute effectively and in a meaningful way?
  • 15. HIV RISK AND PREVENTION
  • 16. Where in the Body is HIV Found?1• HIV lives only in human body fluids. HIV is found in the greatest amounts in these body fluids: – Blood – Semen – Fluid from a woman’s vagina and/or cervix – Breast Milk – Fluid around parts inside the body – fluid around the brain, joints, lungs, heart, belly and amniotic fluid1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 17. HIV Transmission Behavior RISKSharing Injection Equipment MOST RISKReceptive Anal SexReceptive Vaginal SexInsertive Anal SexInsertive Vaginal SexReceptive Oral Sex LEAST RISKInsertive Oral Sex
  • 18. How HIV is NOT Spread.1Through contact with … Fluids that DO NOT transmit HIV• Doorknobs • Saliva• Beds • Tears• Food • Sweat• Clothes• Hugging • Urine• Coughing • Feces• Toilet seats• Mosquitoes• Telephones• Water fountains 1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 19. The Chain of Infection 11. Someone Or Something Must Have The Virus (Source)2. The Virus Needs A Way To Leave The Body (Exit)3. The Virus Needs A Way To Enter Another Persons Body4. HIV Needs Someone Able To Get Infected (Susceptible Host)1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 20. Methods to Prevent the Transmission of HIV• HIV Negative and HIV Positive Individuals – Abstinence from Sexual Activity – Use a condom every time you have sex. – If you inject drugs, dont share your needles or syringes.• HIV-Positive Individuals – Take your anti-HIV medications according to your health care provider’s directions. – Don’t share your razor, toothbrush, or other items that may have your blood on them. – If you are a mother infected with HIV, don’t breastfeed your baby.
  • 21. Prevention for Positives• Prevention with Positives – Secondary Prevention • Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms • Example: Rapid HIV-1 Antibody Testing
  • 22. Prevention for Positives• Prevention with Positives – Tertiary Prevention • Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications. • Example: PCP Prophylaxis
  • 23. Activity• With your partner role play: – How you would explain 1. HIV Risk Behaviors 2. HIV Transmission 3. HIV Prevention
  • 24. HIV DISEASE
  • 25. Viral Life Cycle http://www.haroldsmithlab.com/research_3.htm
  • 26. HIV Disease Progression VL CD4
  • 27. Disease Progression CD4 Cell Count Categories Clinical CategoriesAbbreviations: PGL = persistent generalized lymphadenopathy # A B* C Asymptomatic, Acute HIV, or PGL Symptomatic Conditions, not A or C AIDS-Indicator Conditions (1) ≥500 cells/µL A1 B1 C1 (2) 200-499 cells/µL A2 B2 C2 (3) <200 cells/µL A3 B3 C3 STAGES OF HIV IMAGE, Source: http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-your-body/stages-of-hiv/ Accessed on 09/03/12 WHO/CDC Clinical Staging Chart Source: http://www.aidsetc.org/aidsetc?page=cg-205_hiv_classification Accessed on 09/03/12
  • 28. Activity• With your partner take role play – How you would explain 1. HIV Risk Behaviors/Transmission/Prevention and 2. HIV Life Cycle 3. HIV Disease Progression
  • 29. HIV TREATMENT
  • 30. Why is this important?• ―… one study indicated that 75% of HIV-infected inmates initiated their first antiretroviral treatment while incarcerated.‖1• ―Unfortunately for those receiving HIV-related care, incarceration and/or release can sometimes disrupt HIV treatment regimens and lead to a loss of access to vital ancillary services.‖1• ―Further, delays in HIV treatment and care of new inmates and treatment interruptions, resulting from transfers or disciplinary actions, can lead to missed medications and the possible emergence of drug- resistant HIV strains, particularly in jail settings.‖11Harawa, Nina and Adimora, Adaora. Incarceration, African Americans and HIV: Advancing a Research Agenda. JNatl Med Assoc. 2008 January; 100(1): 57-62
  • 31. HIV Treatment• Anti-retroviral Therapy (ART) – Medication Classes • Entry Inhibitors (EI) • Reverse Transcriptase Inhibtors – Nucleoside/tide Reverse Transcriptase Inhibitors (NRTI) • Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) • Integrase Inhibitors (II) • Protease Inhibitors (PI) – Multidrug Combination Products (also known as Single Regimen Treatment - SRT) http://www.niaid.nih.gov/topics/HIVAIDS/Understanding/Treatment/pages/arvdrugclasses.aspx
  • 32. Medication Targets http://www.bcm.edu/molvir/hivaids
  • 33. Medications by Type/Class NRTIs NNRTIs PIs EIs IIs STRsCombivir* Endurant Aptivus Fuzeon Isentress Atripla* Emtriva Intelence Crixivan Selzentry Dolutegravir Complera* Epivir Recriptor Invirase Elvitegravir The Quad**Epzicom Sustiva Kaletra Retrovir Viramune LexivaTrizivir* NorvirTruvada* Prezista Videx Reyataz Combicistat – booster Viread Viravept medication for Protease Inhibitors Zerit Indicates: * Combination Pill Ziagen ** No Brand Name
  • 34. Antiretroviral Side Effects• Hypersensitivity • Peripheral Neuropathy• Anemia • Vivid Dreams• Diarrhea • Anxiety• Rash • Depression• Constipation • Weight Loss• Nausea • Muscle Pain• Fatigue • Appetite Loss• Chills • Joint Pain• Dizziness • Fat Loss in arms, legs, or• Headaches face• Insomnia • Numbness • Pancreatitis
  • 35. Treatment Guidelines 1 • ART is recommended for all HIV- infected individuals. • The strength of this recommendation varies on the basis of pretreatment CD4 cell count: – CD4 count <350 cells/mm3 (AI) – CD4 count 350 to 500 cells/mm3 (AII) – CD4 count >500 cells/mm3 (BIII)1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/guidelines
  • 36. Treatment Guidelines 1 • Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions: – Pregnancy (AI) – History of an AIDS-defining illness (AI) – HIV-associated nephropathy (HIVAN) (AII) – HIV/hepatitis B virus (HBV) coinfection (AII)1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/guidelines
  • 37. Treatment Guidelines 1 • Effective ART also has been shown to prevent transmission of HIV from an infected individual to a sexual partner. • Therefore, ART should be offered to patients who are at risk of transmitting HIV to sexual partners (AI [heterosexuals] or AIII [other transmission risk groups]).1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 02/22/13 from: http://aidsinfo.nih.gov/guidelines
  • 38. Treatment Guidelines 1 • Patients starting ART should be willing and able to commit to treatment and should understand the possible benefits and risks of therapy and the importance of adherence (AIII). • Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy because of clinical and/or psychosocial factors.1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 02/22/13 from: http://aidsinfo.nih.gov/guidelines
  • 39. Recommended Regimens for Treatment Naïve Patients• Atripla• Reyataz + Norvir + Truvada• Prezista + Norvir + Truvada• Isentress + Truvadahttp://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/11/what-to-start accessed on 03/05/13
  • 40. Laboratory Monitoring SchedulePrior to and After Initiation of ART11Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/aa_tables.pdf
  • 41. Laboratory Monitoring SchedulePrior to and After Initiation of ART11Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 09/03/12 from: http://aidsinfo.nih.gov/guidelines
  • 42. Laboratory Monitoring SchedulePrior to and After Initiation of ART11Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Departmentof Health and Human Services.Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/aa_tables.pdf
  • 43. The Importance of Adherence 1• Anything below 95 percent adherence has been associated with increases in viral load and drug resistance.• Therefore adherence to antiretroviral treatment is extremely important.This means missing no more than onedose a month, if taking antiretroviraldrug treatment once a day.1http://www.avert.org/antiretroviral.htm Accessed on 09/03/12
  • 44. HIV Drug Resistance1• HIV drug resistance refers to the ability of the virus to withstand the effects of a given antiretroviral drug to prevent its replication.• Drug resistant virus will continue to replicate in the presence of the drug to which it has become resistant.• Insufficient knowledge among patients and health workers, suboptimal adherence to treatment regimens, drug stock-outs, and inadequate patient monitoring mechanisms, are among the many factors leading to treatment failure and eventually drug resistance.1World Health Organization. HIV Drug Resistance Fact Sheet. April 2011
  • 45. HIV Drug Resistance1• If patients develop HIV drug resistance to their first-line regimen, they stop responding to it effectively. In order to stay healthy, they need to receive a second-line regimen.• In 2010, in low- and middle-income countries, second-line treatment regimens were on average at least six times more expensive than first-line treatment.• Keeping drug resistance at bay is therefore a key strategy to the success and sustainability of HIV treatment programmes.1World Health Organization. HIV Drug Resistance Fact Sheet. April 2011
  • 46. Tips for ART Adherence 1• Learn about the things that keep HIV patients from taking their meds, and think about how you can deal with them if you have those issues. Some factors include: – Untreated depression/mental illness – Substance abuse – Complicated medical instructions – Medication side effects – Dietary restrictions – Difficulty reading or understanding directions – Homelessness or unstable housing – Stigma – Travel – Overall ―fit‖ of the drug regimen/schedule to the patient’s lifestyle and daily routine1http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/treatment-adherence/index.htmlAccessed on 09/03/12
  • 47. Positively Aware Annual HIV Drug Guide• Published Annually• Reviews ALL Medications• Reviews: – Medication Class – Manufacturer – Dosage – Side Effects/Toxicity – Drug Interactions – Doctor Comments – Community Comments
  • 48. Activity• With your partner take role play – How you would explain 1. HIV Risk Behaviors/Transmission/Prevention 2. HIV Life Cycle/Disease Progression and 3. HIV Treatment 4. HIV Treatment Adherence and Side Effects 5. HIV Drug Resistance
  • 49. OPPORTUNISTIC INFECTIONS
  • 50. Opportunistic Infections• Opportunistic infections are infections that occur if you have a weakened immune system.• People with weakened immune systems can even get infections from organisms that don’t usually cause diseases in health people.• People with AIDS die from Opportunistic Infections, not AIDS or even HIV itself!!!
  • 51. Opportunistic Infections1• Bacterial diseases – tuberculosis, MAC, bacterial pneumonia and septicaemia (blood poisoning)• Protozoal diseases – toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis• Fungal diseases – PCP, candidiasis, cryptococcosis and penicilliosis• Viral diseases – such as those caused by cytomegalovirus, herpes simplex and herpes zoster virus• HIV-associated malignancies – Kaposis sarcoma, lymphoma and squamous cell carcinoma.1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/Accessed on 09/03/12
  • 52. Opportunistic Infections Occurrence by CD4 Count1• Greater than 500 cells/mm3 – In general, people with CD4 counts greater than 500 cells/mm3 are not at risk for opportunistic infections. – For people with CD4 counts around 500, however, the daily fluctuations in CD4 cell levels can leave them vulnerable to minor infections, such as candidal vaginitis or yeast infections.1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/Accessed on 09/03/12
  • 53. Opportunistic Infections Occurrence by CD4 Count1• 500 to 200 cells/mm3 – Candidiasis (Thrush) – Kaposi’s Sarcoma (KS)• 200 to 100 cells/mm3 – Pnuemocystis Jirovecii Pneumonia (PCP) – Histoplasmosis and Coccidiodomycosis – Progressive Multifocal Leukoencephalopathy (PML)1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/Accessed on 09/03/12
  • 54. Opportunistic Infections Occurrence by CD4 Count1• 100 to 50 cells/mm3 – Toxoplasmosis – Cryptosporidiosis – Cryptococcal Infection• 50-100 cells/mm3 – Cytomegalovirus (CMV)• Less than 50 cells/mm3 – Mycobaterium Aviam Complex (MAC)1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/Accessed on 09/03/12
  • 55. Its really quite atrociousSupercalifragilisticexpialidocious You have progressive multifocal leukoencephalopthy
  • 56. Tips for delivering information• Understand the issue yourself• Speaking simply – Not talking down• Allow for questions• Ask patient to repeat back what you have told them• Metaphors can be a helpful tool – Overly complex can be a negative• Confidential Space
  • 57. Activity• With your partner take role play – How you would explain 1. HIV Risk Behaviors/Transmission/Prevention 2. HIV Life Cycle/Disease Progression 3. HIV Treatment/Adherence/Side Effects/Resistance and 4. Opportunistic Infections
  • 58. CO-MORBIDITIES
  • 59. Key Morbidities in HIV 11Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview ofsystematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.
  • 60. Research on HIV Co-Morbidities1• In the United States up to 50% have a mental illness such as depression, and 13% have both a mental illness and substance use issues.• They are also more likely to be co-infected with other sexually transmitted infections, and with hepatitis B and C.1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview ofsystematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.
  • 61. Research on HIV Co-Morbidities1• People with HIV are twice as likely to experience depression compared to the general population.• Coping style and psychological distress are strongly associated with HIV disease progression, even more so than stress stimuli.• Alcohol use is associated with a significant decrease in HAART adherence, however, studies regarding other substance use were inconclusive.• The metabolic effects of combination therapies for HIV increase the risk for insulin resistance, type 2 diabetes and poor cardiovascular disease outcomes.1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview ofsystematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.
  • 62. Research on HIV Co-Morbidities1• The four comorbid conditions that have received the most attention are tuberculosis (TB), Hepatitis C (HCV), other sexually transmitted infections and pneumococcal infections.• HCV increases the risk of mortality for people with HIV and HIV accelerates HCV disease progression.• People with HIV have a statistically greater risk of acquiring TB than the general population.• Multi-drug resistant (MDR) TB is an increasing concern particularly in urban residents, the homeless, and males.1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview ofsystematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.
  • 63. Veteran’s Comorbidity Study• The sample consisted of 33,420 HIV- infected veterans and 66,840 HIV- uninfected veterans.• Comorbidity was common (prevalence, 60%–63%), and prevalence varied by HIV status.1Goulet, Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING ANDINFECTIOUS DISEASES • CID 2007:45 (15 December)
  • 64. Comorbidity Variance• For conditions that tended to decrease in prevalence with age (i.e., substance use disorders, psychiatric disorders, and liver disease), veterans with HIV infection experienced a less pronounced decrease than did HIV-uninfected veterans.• For conditions that tended to increase in prevalence with age (i.e., hypertension, diabetes, vascular disease, pulmonary disease, and renal disease), veterans with HIV infection experienced a more pronounced increase than did HIV- uninfected veterans1Goulet, Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING ANDINFECTIOUS DISEASES • CID 2007:45 (15 December)
  • 65. Comorbidity Variance• Substance use disorders were more common among HIV-infected veterans than among HIV-uninfected veterans (27% vs. 22%; ).• Psychiatric disorders were more common among HIV-uninfected veterans than among HIV-infected veterans (22% vs. 18%; ).1Goulet, Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING ANDINFECTIOUS DISEASES • CID 2007:45 (15 December)
  • 66. Comorbidity Variance• Low CD4 cell count was associated with a decreased odds of substance use disorders and psychiatric disorders.• Detectable viral load was associated with substance use disorders.• Detectable viral load was also associated with a greater risk of having a comorbid condition and multimorbidity.1Goulet, Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING ANDINFECTIOUS DISEASES • CID 2007:45 (15 December)
  • 67. Immunizations for HIV Positive Adults1All Some Not RecommendedHIV Positive Adults HIV Positive Adults HIV Positive Adults• Hepatitis B Virus • Hepatitis A Virus • Anthrax• Influenza • Hepatitis A/Hepatitis B • Smallpox• Polysaccharide Combined Vaccine • Zoster Pneumococcal • Haemophilus• Tetanus and Influenza Type B Diphtheria • Human Papillomavirus Toxoid • Measles, Mumps,• Tetanus, and Rubella Diphtheria and • Meningococcal Pertussis • Varicella1Recommended Immunizations for HIV Positive Adults. AIDSinfo; US Department of Health and Human Services. ReviewedJune 2009.Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/Recommended_Immunizations_FS_en.pdf
  • 68. PSYCHO-SOCIAL IMPACT
  • 69. HIV and Psycho-Social Impact• Stigma and Discrimination• Misinformation• Segregation/Separation Practices• AIDS• Disclosure
  • 70. Coping with HIV and AIDS 1• Denial• Anger• Sadness or Depression• Fear and Anxiety• Stress1Coping withHIV and AIDS: Mental Health. HIVInSite: http://hivinsite.ucsf.edu/insite?page=pb-daily-mentalAccessed on 09/03/12
  • 71. Identifying Emergent Mental Health Needs1• Some changes that might be significant include: – Experiencing ―panic attacks‖ – No longer finding enjoyment in activities which usually make you happy – Withdrawing from social interaction – Change in memory functioning – Sleeping too much—or being unable to sleep – Feeling ―sad‖ or ―empty‖ much of the time – Feeling guilty – Feeling tired all the time1http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/mental-health/index.htmlAccessed on 09/03/12
  • 72. Disclosure Study• Negative consequences included stigma, rejection by sexual partners and others, loss of intimacy, and threats to personal well- being.• Positive rewards resulting from disclosure included increased social support and intimacy with partners, reaffirmation of ones sense of self, and the opportunity to share personal experiences and feelings with sexual partners.1Parsons JT, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDSEducation and Prevention. 2004 Oct;16(5):459-75
  • 73. Activity• In your small group, take ten minutes and using two sheets of newsprint brainstorm the following: – Thinking about disclosure of HIV status to medical staff: • What are the barriers to disclosure? • What are the benefits to disclosure?• Choose a recorder and a presenter to share with the large group your brainstorming.
  • 74. CORRECTIONS
  • 75. Guide for HIV/AIDS Clinical Care1• HIV Care in Correctional Settings – ―Given the high HIV seroprevalence among inmates, the reentry of inmates into the community presents a danger of spreading HIV and other infectious diseases, and it is a public health concern.‖ – ―Education should focus on the use of latex barriers with all sexual activity.‖ – ―… inmates with a history of IDU should be educated about the risks of sharing needles and injection equipment, specifically the high risk of transmitting or acquiring HIV, HCV, and HBV.‖1Department of Health and Human Services. Guide for HIV/AIDS Clinical Care. January 2011.Accessed 09/03/12: http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-00-contributors.html
  • 76. Recommended Counseling Messages• These counseling messages should be reinforced for all inmates diagnosed with HIV infection: – Do not have sex while in prison; do not have unprotected sex upon release to the community. – Do not shoot drugs. – Do not share tattooing or body piercing equipment. – Do not share personal items that might have your blood on them such as toothbrushes, dental appliances, nail clippers or other nail-grooming equipment, or razors. – Cover your cuts and skin sores to keep your blood from contacting other persons, and report to your health care provider should you have an open, draining wound.1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.
  • 77. Recommended Guidance to HIV Infected Inmates• Additionally, inmates with HIV infection should be given the following guidance: – Do not donate blood, body organs or other tissue, or semen. – Always wash hands before eating, after touching contaminated clothing/bedding, after attending to personal hygiene, after gardening or other outdoor activities, after touching animals, or after touching any other contaminated items.1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.
  • 78. Recommended Guidance to HIV Infected Inmates (cont.)• Additionally, inmates with HIV infection should be given the following guidance: – Wash fresh fruits and vegetables thoroughly before eating. – Avoid eating undercooked or raw meats. – Stop smoking, and do not begin smoking again upon release. – Avoid touching stray animals.1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.
  • 79. Staff Guidance for Infection Control When Managing Inmates• Staff should use the following infection control guidelines when managing inmates: – Use correctional standard precautions when in contact with any inmate’s blood or other potentially infectious materials, whether or not the inmate is known to have HIV infection. – Use infection control practices in which non-disposable patient-care items are appropriately cleaned, disinfected, or sterilized – Take measures to prevent cross-contamination during patient care (e.g., dialysis, vascular access, cauterizing, or dental procedures) – Use the appropriate airborne, droplet, and/or contact transmission precautions1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.
  • 80. Correctional Officers 1 Know how HIV/AIDS is and is not transmitted. Respond to issues that impact an inmate’s treatment for HIV; your efforts will benefit your job, your fellow officers and the community you live in. Confidentially refer inmates to health services and to other programs such as peer education, substance abuse and/or mental health programs.1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 81. Correctional Officers 1Keep open communications with facility health staff.Challenge coworkers, friends and family members regarding myths and beliefs about HIV/AIDS.Incorporate standard precautions and prevention techniques into day-to-day work to reduce/eliminate the spread of HIV/AIDS.1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 82. Correctional Facility ―To Do List‖1• Policy and Procedures – to safeguard the confidentiality and prohibit any unauthorized disclosure of confidential HIV related information, inside or outside the facility – specifying when there is a “reasonable need” to get or use confidential HIV related information (for the purpose of supervising, monitoring, administering, or investigating the programs and health or social services the facility coordinates with)1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 83. Correctional Facility ―To Do List‖1• Provide safeguards to prevent discrimination or abuse of inmates who have been tested for or diagnosed with HIV/AIDS• Prevent and deal with occupational exposure where there is a significant risk of HIV transmission• Provide training for staff on confidentiality and the facility’s ―need to know‖ policy1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute
  • 84. Opportunities for Clinicians to Educate Patients1 Medical care providers can affect HIV transmission by: 1. Screening their HIV-infected patients for risk behaviors 2. Communicating prevention messages 3. Discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior 4. Referring patients for servicesMMWR; Recommendations and Reports. July 18, 2003 52(RR12);1-24. CDC. July 18, 2003.
  • 85. Discussion• What role can corrections play in the fight against HIV in our communities and in our facilities? – Prevention – Treatment – Education – Empowerment?
  • 86. RESOURCES
  • 87. Comprehensive HIV/AIDSResources and Linkages for Inmates
  • 88. Resources• US Department of Health and Human Services – www.aids.gov• Centers for Disease Control and Prevention – www.cdc.gov• Health Resources and Services Administration – www.hrsa.gov• AIDS Info – www.aidsinfo.nih.gov• US Department of Justice – www.usdoj.gov• Virginia Department of Health – www.vdh.virginia.gov
  • 89. Final Thought …America is a nation of second chances andthose leaving prison should have theopportunity to change. Governor Bob McDonnell 2011 State of the Commonwealth
  • 90. Closing and Evaluation• Questions?• One thing you learned that you didn’t know? Thank you!