HIV & Jails: A Public Health Opportunity
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HIV & Jails: A Public Health Opportunity

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This Webinar is the first in the Enhancing Linkages to HIV Primary Care and Services Webinar series, produced in association with the Health Resources and Services Administration's (HRSA's) ...

This Webinar is the first in the Enhancing Linkages to HIV Primary Care and Services Webinar series, produced in association with the Health Resources and Services Administration's (HRSA's) Integrating HIV Innovative Practices (IHIP) project. The series’ three sessions each focus on a different aspect of linking people living with HIV/AIDS to HIV primary care and services in the jails setting.

This Webinar series is part of a collection of dissemination materials on the SPNS EnhanceLink Jail Linkage Initiative (http://hab.hrsa.gov/abouthab/special/carejail.html). These include:
- Training manual: https://careacttarget.org/library/creating-jail-linkage-program-training-manual
- Curriculum: https://careacttarget.org/library/creating-jail-linkage-program-curriculum, and
- Pocket guide: https://careacttarget.org/sites/default/files/JailsLinkageIHIPPocketCard.pdf
All of these resources can be found on the IHIP landing page (http://www.careacttarget.org/ihip) on the TARGET Center Web site. In addition, all Webinar sessions in this series will be recorded and also made available on the IHIP page.

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  • Taking a snapshot of all those behind bars on a given day, 2/3 are in prison, 1/3 are in jail. ACS The majority of people passing through a correctional institution pass through a jail, not a prison.
  • HBV, hepatitis B virus; HCV, hepatitis C virus; STI, sexually transmitted infection; TB, tuberculosis.   This slide illustrates my concept of the challenge of continuum of care. I envision a cycling from incarceration to freedom to reincarceration, and we have to think about opportunities to break the cycle. During incarceration, we have to ask ourselves whether we are doing the best we can in diagnosing HIV and other infectious diseases, in diagnosing concomitant mental illness and substance abuse, and in dealing with those patients during incarceration by offering treatment and counseling. Before release, are we linking people to community care in meaningful ways?   Once patients get out of prison or jail, how well do maintain the benefits of care experienced during incarceration? I have presented data that people in care during their prison incarceration experience benefits of this care––HIV-1 RNA decreases and CD4+ cell count increases––but those benefits are often lost after release. The challenge is to provide more effective models to link people to care in a timely way so that we can protect them from adverse consequences and protect others with whom they may have intimate relationships or share needles.   Adequate community resources are a must. Many communities are being blighted with a lack of resources, and we have to try to link people to better care.   Finally, we must address reincarceration. In our study of bridging case management, we saw 30% of people being reincarcerated within 6 months of release. How do we break that cycle? This is a challenge not just to us who work with incarcerated populations but also to society. The problem stems from overarching themes of poverty, discrimination, racism, and sentencing laws. This challenge is complicated and requires linkages between healthcare and public health authorities and with government officials and policymakers to break the cycle.
  • How our outcomes related to the national care continuum
  • Reveals the overlap of correctional populations with other target groups in the HIV epidemic
  • Thank you for your time -My contact information and the Impact Marketing + Communications Website are at the bottom, so please feel free to reach out any time if you have questions about our firm, the IHIP work or any other HRSA deliverables we’ve created, or if there are any marketing or communications projects we can help you with. - At this time, I’d be happy to take any questions you have about the IHIP project. We will also turn to Q&A with the other presenters.

HIV & Jails: A Public Health Opportunity HIV & Jails: A Public Health Opportunity Presentation Transcript

  • HIV and Jails: A Public Health Opportunity September 19, 2013
  • Agenda Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project Sarah Cook-Raymond, Impact Marketing + Communications Presentations from  Barry Zack,The Bridging Group  Dr. Anne Spaulding, Emory University Q & A
  • IHIP Jail Linkage Resources:  Lessons Learned Manual  Implementation Guide  Webinar Series  HIV and Jails: A Public Health Opportunity – today’s Webinar September 19, 2013 (archive recording will be up shortly)  How to Build and Expand a Jail Linkage Program – September 27, 2013 at 12pm ET  Creating Partnerships and Navigating the “Culture of Corrections”- October 3, 2013 at 2pm ET www.careacttarget.org/ihip
  • Other IHIP Resources  Buprenorphine  Training Manual, Curricula, and Webinars on Implementing Buprenorphine into Primary Care Settings  Engaging Hard-to-Reach Populations  Training Manual, Curricula, and Webinars on Engaging Hard-to-Reach Populations  Oral Health  Forthcoming:Training Manual, Curricula, and Webinars on Oral Health and HIV
  • Enhancing Linkages to HIV Primary Care and Services in Jail HIV and Jails: A Public Health Opportunity Barry Zack September 19th, 2013 The Bridging Group
  • Outline: • Introduction (brief) to U.S. Correctional System • Epidemiology of Health / Corrections • Public Health and Public Safety • Linkages: Continuity of Care
  • United States Incarceration Rates • More than 1 in 100 American adults were incarcerated at the start of 2008. • One in every 31 American adults, or 7.3 million Americans, are in prison, on parole or probation. • US has over 25% of all people incarcerated worldwide. • Approximately one in every 18 men in the US is behind bars or being monitored.
  • 9 Jails in the United States  85% of incarcerated individuals pass solely through jails  Each year this accounts for nearly 13 million jail admissions—representing 9 to 10 million unique individuals—in the United States.  This equates to approximately 4% of the U.S. adult population passing through a jail in a given year. 9
  • 10
  • Criminal Justice System • Law enforcement ▫ Police, sheriff, highway patrol, FBI, etc. • Adjudication ▫ Courts • Corrections ▫ Jails, prisons, probation and parole
  • Types of Correctional Supervision • Probation • Jail Custody • Prison Custody • Parole
  • Distribution of Population
  • Jail vs. Prison • Jail ▫ Operated by local law enforcement agency (e.g. County Sheriff’s Department) ▫ Pre-Trial, Trial, Short Term Sentences (usually up to one year) ▫ Range of offenses (e.g., misdemeanor & felony) • Prison ▫ Typically operated by State DOC or Federal BOP ▫ Tried and convicted ▫ Felony offenses • Private Jails and Prisons: local and state agencies may also contract these operations to a private entity
  • Why Jails? Over 95% of persons released from correctional facilities leave jails! Annual Admissions Average Daily Population
  • Security Levels •  Minimum ▫ Not considered a serious risk to the safety of staff, peers or to  the public ▫ Many facilities have transitional/re-entry programs • Medium ▫ May present a risk of escape or pose a threat to peers or staff ▫ May have programs buy may be based on individual’s  conforming behavior with institutional rules and regulations • Maximum ▫ Maximum  control and supervision through the use of high  security parameters, internal physical barriers and check  points ▫ Present serious escape risks or pose serious threats to  themselves, peers, or staff ▫ May have limited access to programs
  • Percent of Total Burden of Infectious Disease passes through Jails/Prisons • Total HIV/AIDS                   15% • Chronic Hepatitis B             12-16% • Hepatitis C                             29-32% • TB Disease                             38%
  • Health and Incarceration • STDs - significantly higher • Mental Illness - 45-64% ▫ 10-17% SMI • Substance Use – 43-69% ▫ 30% have co-occurring SMI • Aging related - significantly higher ▫ Hypertension ▫ Diabetes
  • Prevalence of Various Conditions Compared to General US Population 4.1 5.5 17 11 13 0 2 4 6 8 10 12 14 16 18 HIV AIDS HCV TB Mental Illness FoldIncreaseinPrevalence
  • HIV prevalence (%) in selected countries 0 5 10 15 20 25 30 35 40 45 Canada Brazil USA Honduras Spain RF Vietnam Indonesia Ukraine South Africa Adults Prisoners
  • HIV Prevalence Among Those Released From Prison/Jail in 2006 Estimate of proportion of HIV+  persons in US who passed  through a jail or prison in 2006 1 of 7 (14.1%) of all HIV+ in US  were released from  incarceration in 2006 At least 22% of all HIV+ black  men in US passed through a  correctional facility during  2006 Incarcerated/released Not incarcerated Total US HIV population ~ 1.1 million Spaulding A, et al. PLoS One. 2010. 85.9 14.1
  • HIV Prevalence in the 12 City Jails: Metropolitan Statistical Area Average  Daily Jail Population   Estimated HIV Prevalence Rates Atlanta, Georgia   Baltimore, Maryland   Chicago, Illinois   Dallas, Texas   District of Columbia   Houston, Texas   Los Angeles, California   Miami, Florida   New York City, New York   Philadelphia, Pennsylvania   San Juan, Puerto Rico   San Francisco, California  
  • HIV Transmission in Correctional Settings • Majority of people with HIV are infected before they enter prison1 • HIV risk behaviors often continue inside the institution and include  injecting drug use, tattooing, body piercing, and consensual,  nonconsensual, and survival sexual activities2 • Scarcity of sterile drug paraphernalia leads to syringe sharing in  prison3 • Syringe sharing among soon-to-be released individuals is high4 1. CDC. MMWR. 2006;55(15):421-426. 4. Stephens TT et al. Am J Health Stud. 2005. 2. Hammett TM. Am J Pub Health. 2006;96(6):974-978. 3. Davies R. Lancet. 2004:364:317-318.
  • Cycle of Incarceration Community Jail Court Prison
  • Relationships in the Community
  • When Prison Enters the Picture
  • Concurrent Relationships in the Community
  • A Community at Risk • Reality Check: ▫ It is estimated that each year, approximately 14% of  all HIV positive persons in the US spend time in prison or  jail. • People come into facilities with higher rates of infectious diseases • Most people (over 90%) in correctional facilities will return to the community • Incarcerated does not occur in a vacuum.  People move in and  out of prisons and jails and likewise move in and out of  communities and relationships. • Correctional medical care and health programs represent access 
  • Unique Access • High turnover of people in prisons and jails  creates a flow of individuals who may have  access to health care only when incarcerated. • The correctional setting may be the only place  where people get care, treatment and support.
  • The Collaboration: Culture of Corrections • Working within/inside a Correctional Setting • Working with the Correctional System • Patience & Persistence….
  • Issues to Consider • Disconnect between Corrections and Public Health • Different Cultural Identities • Security= Safety First • Operational Policies, Procedures and Relationships • Confidentiality • Ethical Considerations
  • The Disconnect Public Health Jail & Prison  Mission = Public Health  Orientation toward Change  Humanitarian  Dress code is (more) Informal  Prevention/Screening/Care  Client/Community-Centered  Flexibility  Creative  Mission = Public Safety  Orientation toward Order  Para-Military  Dress code is Uniform  Punishment (rehabilitation….)  Institution-Centered  Rules  Standard Operating Procedures
  • Addressing Public Health Supports the Mission of Public Safety • Safety and security is the number one priority of every correctional facility. • Evidenced based health education, prevention, screening and continuity of care, post release, can contribute to the safety and security mission of a detention setting. “People, who are actively working to better themselves, are less likely to get into trouble on the inside. Thus, more programs make my prison safer.” - Former Warden, San Quentin State Prison
  • The Linkages Challenge: What are we doing? Screening Diagnosis – Infectious diseases (HIV, STI, TB, HCV, HBV) – Mental illness – Substance abuse  Treatment  Pre-release planning Making the transition work!  Linkage to care and services Treatment ID (HIV, HCV, STIs, HBV, etc.) Chronic (hypertension, diabetes) Substance Use & Mental Health  Adequate community resources Addressing life’s competing priorities How to break the cycle?  Societal challenge (poverty, discrimination, etc.)  Policy (Sentencing, Drugs, Housing, Sex Offenders) Incarceration Freedom Reincarceration
  • Project START for People with HIV • RCT ▫ Individual and Ecosystem ▫ Jail and Prison • Medication use • Medication adherence • Recidivism • Sexual behavior
  • New & Ongoing Issues to Consider: • ACA ▫ Major CJ implications: time of enrollment and eligibility to coverage of mental health and substance use treatment • Criminogenicity • Electronic Medical/Health Records ▫ HIPAA, consent • Multi-lingual / cultural competency ▫ Context of CJ and Medical Care  Conditions of Probation and Parole • Patient’s life competing priorities ▫ Income, housing, family, etc. • Trust & Relationships & Linkages ▫ Medical, Healthcare and CJ systems
  • HIV Linkages to Care • Linkages to HIV treatment providers in the community after release • Seamless medical care • Additional support services ▫ case managers, benefits counselors • Access to other treatment providers ▫ substance treatment, mental health, etc.
  • In conclusion: • Most people in jail will return to the community • People coming into jail (as a population) are relatively unhealthy • The burden of disease is much greater than in the general population • Critical to comprehend the context of the criminal justice system to pro-actively work with systems and patients
  • In Conclusion: •The jail setting represents access to a population to improve community health.
  • Thank you…. For more information: •www.thebridginggroup.com •barry@thebridginggroup.com
  • EnhanceLink Initiative to Link HIV+ Jail Releasees to Community Care – A Legacy of Lessons Learned Anne Spaulding MD MPH—Emory University, Atlanta Georgia PI, EnhanceLink Evaluation and Support Center Funder: HRSA Dates: September 2006 – August 2012 Number of Sites: 10; Number of Jails Served: 20 Cost: $22 Million
  • Major Activities: HIV Testing & Continuity of Care Programs Enrollment Jail Discharge Six Months Post-Release Discharge Planning Intensive Case Management Court Advocacy Basic Needs like Transportation Health, HIV care & Social Service NeedsHousing TESTING
  • Enhance Link Care Sites and Partners Evaluation and Support Center: Emory University/Abt Associates
  • Jail Admission (n=877,119) Jail Admission (n=877,119) Offered HIV Testing (n=499,131) Offered HIV Testing (n=499,131) Tested for HIV (n=210,267) Tested for HIV (n=210,267) HIV-positive Test Result (n=1,312) HIV-positive Test Result (n=1,312) Previously Known HIV + (n=27,827) Previously Known HIV + (n=27,827) Offered Transitional Linkage Services (n=9,837) Offered Transitional Linkage Services (n=9,837) Newly Diagnosed HIV + (n=822) Newly Diagnosed HIV + (n=822) Sum of instances when HIV+ persons known to be in jail = 28,649 Enrolled in Client Level Portion of Multi-Site Evaluation (n=1,386) Enrolled in Client Level Portion of Multi-Site Evaluation (n=1,386) Enrolled in Transitional Linkage Services (n=8,056) Enrolled in Transitional Linkage Services (n=8,056) EnhanceLink Study Population Admission, Testing & Service Events
  • • Ten manuscripts have been submitted • Special issue will also include: ▫ An overview authored by the Guest Editors ▫ Commentary by AT Wall, Director of the Rhode Island Department of Corrections ▫ Appendix detailing methods of the EnhanceLink initiative AIDS AND BEHAVIOR SPECIAL ISSUE
  • Planning for Success Predicts Virus Suppressed Spaulding, Messina, Kim et al., AIDS and Behavior • 26% of releasees had VL <400 at 6 months post release – Conservative estimate: those for whom data missing were assumed to be UNSUPPRESSED. – Not all persons who were linked were eligible for ART • Factors associated with viral suppression include: – Involvement of case managers in assessing and providing care • These results support further development of case management programs for HIV-positive jail detainees
  • Cost Analysis of Enhancing Linkages to HIV Care Following Jail: A Cost-Effective Intervention (Spaulding et al, AIDS and Behavior) • Mean cost per linked client: $4,219 • Mean cost per 6-month sustained linkage: $4,670 • Mean cost/client achieving viral suppression: $8,432 • Cost per additional quality adjusted life year saved: $72,285 →cost-effective Data suggest EnhanceLink interventions were cost- effective from a societal perspective • But we had to extrapolate from other studies • How many participants would have linked even without EnhanceLink??
  • Poll 1. What percentage of HIV+ men in a jail population acquired their infection through having sex with men? a. 2% b. 6% c. 20% d. 40% 2. Is the presence of a serious mental illness in a jail releasee associated with a higher or lower likelihood of linkage/retention in care after release? 3. If 28% of persons in the US with HIV have suppressed virus, what percentage of persons leaving jail can achieve viral suppression at 6 months when linkage services are available? 4. If models of excellence are now established in 20 jails across the US, how do we transfer information to the other 3200? OTHER FINDINGS
  • Poll 1. What percentage of HIV+ men in a jail population acquired their infection through having sex with men? a. 2% b. 6% c. 20% d. 40% 2. Is the presence of a serious mental illness in a jail releasee associated with a higher or lower likelihood of linkage/retention in care after release? 3. If 28% of persons in the US with HIV have suppressed virus, what percentage of persons leaving jail can achieve viral suppression at 6 months when linkage services are available? 4. If models of excellence are now established in 20 jails across the US, how do we transfer information to the other 3200?
  • Poll 1. What percentage of HIV+ men in a jail population acquired their infection through having sex with men? a. 2% b. 6% c. 20% d. 40% 2. Is the presence of a serious mental illness in a jail releasee associated with a higher or lower likelihood of linkage/retention in care after release? 3. If 28% of persons in the US with HIV have suppressed virus, what percentage of persons leaving jail can achieve viral suppression at 6 months when linkage services are available? 4. If models of excellence are now established in 20 jails across the US, how do we transfer information to the other 3200?
  • Poll 1. What percentage of HIV+ men in a jail population acquired their infection through having sex with men? a. 2% b. 6% c. 20% d. 40% 2. Is the presence of a serious mental illness in a jail releasee associated with a higher or lower likelihood of linkage/retention in care after release? 3. If 28% of persons in the US with HIV have suppressed virus, what percentage of persons leaving jail can achieve viral suppression at 6 months when linkage services are available? 4. If models of excellence are now established in 20 jails across the US, how do we transfer information to the other 3200?
  • HOW DID EMORY/AID ATLANTA SUSTIN PROGRAM AT FULTON COUNTY (GA) JAIL
  • RE-ESTABLISHMENT OF RAPID TESTING CONTINUED LINKAGE SERVICES
  • Poll 1. What percentage of HIV+ men in a jail population acquired their infection through having sex with men? a. 2% b. 6% c. 20% d. 40% 2. Is the presence of a serious mental illness in a jail releasee associated with a higher or lower likelihood of linkage/retention in care after release? 3. If 28% of persons in the US with HIV have suppressed virus, what percentage of persons leaving jail can achieve viral suppression at 6 months when linkage services are available? 4. If models of excellence are now established in 20 jails across the US, how do we transfer information to the other 3200?
  • CHALLENGES OF TRANSFERRING INFORMATION
  • Jail linkage more imperative for HIV clinics than for jails • Only 1-2 out of 100 inmates/releasees has HIV. • 1 out of 6 persons with HIV in the US is in either a jail or a prison at least part of the year. Source: Spaulding, PLoS One 2009 Must keep in mind…
  • HERE IS A TYPICAL MEDIUM SIZED JAIL: SPALDING COUNTY (GA)
  • CHALLENGES AFTER ENHANCELINK • Diffusion of information into non-grantee jails • Finding champions within local jails • Finding champions within local health departments • Funding streams to underwrite programs • Additional data to show cost-effectiveness of jail/community linkage programs for HIV infected detainees
  • Q&A Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300 Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications | To be informed when these upcoming IHIP resources are ready, sign up for the IHIP listserv by emailing scook@impactmc.net.