What Happens to HIV+ Inmates in the SD County Jail System, Stays in the SD County Jail System: Challenges and Opportunities
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What Happens to HIV+ Inmates in the SD County Jail System Stays in the SD County Jail System (at least until the MDbecomes a snitch) - Challenges and Opportunities Daniel Lee, MD Clinical Professor of Medicine UCSD Medical Center – Owen Clinic December 7, 2012
OutlineDifference between Jails and PrisonsEpidemiology of HIV in CorrectionsTour of the San Diego County Jail systemChallenges and Opportunities in SD Jails– Intake visit– Managing HIV– HIV testing– Discharge– Retention into medical care
Differences between the Jail System and Prison System Jail Prison Prior to sentencing After sentencing – Awaiting trial or transfer – if convicted for a long time – Inability to post bail Long-term sentence – Detainees picked up on – Usually > 1 year* with mean suspicion of committing a duration of 3 years crime More extensive amenities Short-term sentence – Exercise areas – Usually < 1 year* with median – Common areas for eating and duration of 48 hours socializing Amenities – Church facilities – Minimal or very limited – Educational facility*To deal with overcrowding in the jails, AB109 mandated that the jails would now be responsible fortaking care of inmates who are incarcerated up to 3 years
Assembly Bill 109 Signed in 2011 by Governor Brown to reduce the number of inmates in the state’s 33 prisons by 5/24/13 as ordered by the Supreme Court – Allows non-violent, non-serious, and non-sex offenders to serve their sentence in county jails instead of state prisons – No inmates currently in state prison will be transferred to county jails or will be released early – All felons sent to state prison will continue to serve their entire sentence in state prison – All felons convicted of current or prior serious or violent offenses, sex offenses, and sex offenses against children will go to state prisonCalifornia Department of Corrections and Rehabilitation Fact Sheet, 7/15/11.
Persons Subject to Correctional Oversight, 2010 8 7.08 Estimated Number of People in United States Supervised by Number of Individuals 7 Adult Correctional Systems, by Correctional Status 6 (Millions) 5 4.06 4 3 2 1.5 0.84 0.75 1 0 Total Population* Probation Parole Prison‡ Local Jails§ Community supervision Incarcerated† Note: Estimates rounded to the nearest 100. Data may not be comparable to previously published BJS reports because of updates and changes in Number of individuals released into the community annually : 2 reference dates. Community supervision, probation, parole, and prison custody counts are for December 31 within the reporting year; jail population counts are for June 30. The 2007 and 2008 totals include population counts estimated by BJS because some states were unable to provide data. See Methodology. *Estimates were adjusted to account for some offenders with multiple correctional statuses. Details may not sum to total. See Methodology. Jails → 8,600,000 †Includes jail inmates and prisoners held in privately operated facilities. ‡Includes prisoners held in the custody of state or federal correctional facilities or privately operated facilities under state or federal authority. The custody prison population is not comparable to the jurisdiction prison population. See the text box on page 2 for a discussion about the differences between the two prison populations. Prisons → 597,000 §Estimates were revised to include all inmates confined in local jails, including inmates under the age of 18 years who were tried or awaiting trial as an adult and the number held as juveniles. Totals for 2000 and 2006 through 2010 are estimates based on the Annual Survey of Jails. See appendix table 4 for standard errors. Total for 2005 is a complete enumeration based on the 2005 Census of Jail Inmates. See Methodology.1. Glaze LE. Correctional Populations in the United States, 2010. Washington, DC: Bureau of Justice Statistics; December 15, 2011.2. Springer SA, et al. CID. 2011;53:469-479.
HIV and AIDS: US Population vs. Imprisoned Population In the US, HIV is approximately 3 times more prevalent and AIDS is 2.5 times more prevalent among imprisoned people compared with the US population* Total number of HIV-infected inmates or inmates with confirmed AIDS held in state or federal prisons at year’s end in 2008: 21,987 (1.5% total population)* *Data as of 12/31/2008 (most recent available)CDC. HIV/AIDS surveillance report, 2009. Vol. 21. www.cdc.gov/hiv/surveillance/resources/reports/2009report. Accessed February 28, 2011.*Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
Number of HIV Infections in Incarcerated Populations by State* 9 states have >500 inmates with HIV infection† Nine states have <20 inmates with HIV infection: Alaska, Maine, Montana, Nebraska, New Hampshire, North Dakota, South Dakota, Vermont, and Wyoming *Information not available for Indiana † Data as of 12/31/2008 (most recent available); includes inmates of both state and federal prisonsMaruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
Rate of HIV Infection in Incarcerated Populations by State* 11 states have higher-than-average rates of HIV infection in imprisoned populations† *Information not available for Indiana † Data as of 12/31/2008 (most recent available); includes inmates of both state and federal prisonsMaruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
HIV Infections by Incarceration, Status, and Sex In the US, most people infected with HIV are male. The difference is more pronounced in the imprisoned population* US Population Imprisoned Population with HIV Infection with HIV Infection *Data as of 12/31/2008 (most recent available)CDC. HIV/AIDS surveillance report, 2009. Vol. 21. www.cdc.gov/hiv/surveillance/resources/reports/2009report. Accessed February 28, 2011.Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
Rates of HIV Infection are Higher inIncarcerated Women Compared to Men Compared with the US population, rates of HIV infection are10 times higher in women and 3 times higher in men who are incarcerated In the US in 2008, 24% of new HIV infections were in women. 85% of these women were infected through heterosexual contact. *Data as of 12/31/2008 (most recent available) CDC. HIV/AIDS surveillance report, 2009. Vol. 21. www.cdc.gov/hiv/surveillance/resources/reports/2009report. Accessed February 28, 2011. Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
US and Imprisoned Populations by Race/Ethnicity People of color are also overrepresented in the imprisoned population US Population* Imprisoned Population† (N=310,200,000) (N=1,548,700) White Hispanic/ Latino Black/African American Other No recent data exist on the racial/ethnic distribution of HIV infection among inmates in the US *Projected data for 2010 †Estimated data as of 12/31/2009 (most recent available), including inmates of both state and federal prisonsKaiser Family Foundation. Distribution of US population by race/ethnicity, 2010 and 2050. facts.kff.org/chart.aspx?ch=364. Accessed February 28, 2011.US Department of Justice. Prisoners in 2009. bjs.ojp.usdoj.gov/content/pub/pdf/p09.pdf. Accessed February 22, 2011.
Leading Causes of Death in Federal Prisons Within federal prisons, AIDS is the third leading cause of death* *Data from 2008 (most recent available), including federal agency-managed institutions only †50% of accidental deaths were due to drug or alcohol intoxicationMaruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
Rate of AIDS-Related Deaths in State Prisons by Race/Ethnicity Within the state prison system, people of color are more likely to die from AIDS-related causes* *Data from 2007 (most recent available)Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.
Polling Question #1If you were arrested, who do you want tobe your best friend?1. “C/O”2. “Doc”3. “Cellie”4. “Greenbander”
Polling Question #1If you were arrested, who do you want tobe your best friend?1. “C/O”2. “Doc”3. “Cellie”4. “Greenbander”The answer is probably 1, 2, or 3 (depending onwhat you need)
San Diego County Jail SystemSan Diego Central Jail (SDCJ)George Bailey Detention Facility (GBDF)Vista Detention Facility (VDF)Facility 8 Detention Facility (F8DF)East Mesa Detention Facility (EMDF)South Bay Detention Facility (SBDF)Las Colinas Detention Facility (LCDF)
HIV Care at San Diego JailsJail medical care in San Diego iscurrently provided by UCSDEmergency Medicine DepartmentHIV specialty care is subcontractedout to Owen Clinic– All HIV+ inmates are sent to SDCJ for HIV medical care– Weekly HIV Clinic on Tuesday PMs (direct patient care) at San Diego Central Jail since 12/28/98– Average of 10-15 inmates/week (Range 5-20)
Jail Entry and IntakeInmates are seen by physician for initialmedical intake visit– Review of past medical history– Medications for acute or chronic medical conditions may be started HAART may or may not be started– Labs may be ordered if needed HIV-specific labs may or may not be ordered– Old records are ordered– Referred to Tuesday PM clinic for HIV-specific care
Tuesday 1PM HIV ClinicInmates are sent from outside jails and transferred earlyin the AM to SDCJ– Assessment of jail-related factors – may affect plan of action When is the upcoming court date? Likelihood of release? Prison time or not?– Review of HIV-related history/ARV history and old records/UCSD records (EPIC)– Consider restarting HAART– Consider ordering HIV-specific labs– Address other concerns Diet “Chronos”– Transitional case manager assessment of inmate interest in drug/EtOH rehabilitation programs
Factors to Consider When Starting HAART in a Correctional Setting Incarcerated patients face additional challenges with antiretroviral therapy, including: – Confidentiality – Necessity of visiting medication lines on a regular basis – Distribution methods: keep on person (KOP) or directly-observed therapy (DOT) – Availability of food and water may not correspond with conditions needed for specific antiretroviral medications – Detention in segregation or other area where medications are not accessible – Policies and procedures focused on security that may not allow for needed flexibilityAIDS Education and Training Centers National Resource Center. Correctional Settings. http://www.aids-ed.org/aidsetc?page=cm-801_corrections. Accessed April 12, 2011.Stephenson B, Leone P. HIV care in U.S. prisons: the potential and challenge. www.thebodypro.com/content/art14528.html. Accessed April 12, 2011.
Polling Question #2In addition to starting HAART, let’sassume you were also trying to “score”pain medications, what is the most likelydiagnosis you should claim to have?1. Back pain2. Toothache3. Neuropathy4. Rib pain5. None, just trade with someone who gets it “legit”
Polling Question #2In addition to starting HAART, let’sassume you were also trying to “score”pain medications, what is the most likelydiagnosis you should claim to have?1. Back pain2. Toothache3. Neuropathy4. Rib pain5. None, just trade with someone who gets it “legit”The correct answer is Neuropathy
HIV Testing Is Underutilized in the Corrections System 25 23 Many prison systems provide testing on request or based on 20 clinical indication or risk factors Only 2 states (Missouri and States Testing, No. 15 Nevada) test at all 3 time points 10 Not all states use opt-out testing practices as 6 recommended by the Centers 5 5 for Disease Control and Prevention (CDC) 0 Entering In Custody On Release CustodyDwyer M, et al; HIV/AIDS Bureau. HIV care in correctional settings. Guide for HIV/AIDS Clinical Care. Rockville, MD: Health Resources and ServicesAdministration; January 2011.
HIV Screening Is Cost Effective Even When the Prevalence Is Substantially <1% Cost-effectiveness of a One-time Screening Program vs No Screening in the General Population1 Incremental Cost-Effectiveness 200,000 180,000 of Screening, $/QALY 160,000 140,000 120,000 100,000 80,000 Costs and benefits to partners excluded 60,000 40,000 Costs and benefits to partners included 20,000 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Prevalence of Unidentified HIV, % The prevalence of HIV in many incarcerated populations is >1%2 – CDC3: Patients aged 13-64 years should be screened for HIV in settings with prevalence ≥0.1% QALY, quality-adjusted life year.1. Adapted from Sanders GD, et al. N Engl J Med. 2005;352:570-585. ®New England Journal of Medicine. 2. Beckwith C, et al; Centers for Disease Control andPrevention. HIV Testing Implementation Guidance for Correctional Settings. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health& Human Services: January 2009: 1-38. 3. Viall AH, et al; Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2011;60:805-810.
Testing Programs Can Bridge the Gap from Custody to Community Individuals unaware of their HIV-positive status are 3.5 times more likely to transmit the virus Testing, upon intake, is especially important for jail inmates due to typically shorter stays Knowledge of HIV status lowers risk-taking behaviors with others by 50%Altice FL, et al. Jail: time for testing. www.enhancelink.org/sites/hivjailstudy/Training Manual ready to print.pdf. Accessed March 19, 2012.
HIV-Related Testing and Post- Exposure Prophylaxis at SDCJHIV-related tests– HIV antibody testing is not proactively offered at intake or at discharge, but available upon request– HIV rapid tests are not available– HIV antibody tests consist of EIA with confirmatory CIA – turnaround time ~ 2 wks– All those tested for HIV are referred to Tuesday PM for review of HIV test results– CD4/VL (RNA PCR tests) – turnaround time ~2 wks– HIV Genotype testing (Quest) – turnaround time ~2-4 wksPost-exposure prophylaxis– All inmates are started on LPV/RTV with TDF/FTC and single- dose NVP x 28 days and HIV antibody testing sent
Polling Question #3What is the most commonly “cheeked”non-narcotic pain medication?1. Ibuprofen2. Tramadol3. Gabapentin4. Indocin
Polling Question #3What is the most commonly “cheeked”non-narcotic pain medication?1. Ibuprofen2. Tramadol3. Gabapentin4. IndocinThe correct answer is tramadol, but gabapentinis a common as well
Jail Discharge at SDCJInmates are discharged typically in lateevening/early morning by discharge MD– Psych medications are given upon discharge– A prescription for a 30-day supply of HIV medications is given to the inmate or faxed to Hillcrest Pharmacy (contract with Jail to supply HIV medications) if written by the discharge MD– Other ancillary medications (ie. diabetes medications, antihypertensives, or pain medications) may or may not be written for upon discharge
The Transition to the Community Is an Especially Vulnerable Time Many inmates received an HIV-positive diagnosis while incarcerated – 75% initiate ART while in custody, but many discontinue therapy once released ≥90% of newly released inmates do not fill ART prescriptions in time to avoid treatment interruption – >80% do not fill their prescriptions within 30 days of releaseBaillargeon J, et al. JAMA. 2009;301:848-857.
The Hierarchy of Needs for the HIV- infected Former Inmate Risk behavior HIV modification Mental illness management Drug dependence management Case management: Shelter, food, employment, and safetySpringer SA, et al. CID. 2011;53:469-479.Reproduced with permission of Oxford University Press in the format Journal via Copyright Clearance Center.
HIV+ Individuals Returning to the Community Face Many Obstacles HIV-positive South Florida Inmates Require Assistance on Release1 Additional obstacles2 – Anti-Drug Abuse Act of 1988 80 May be denied public 70 67 housing if convicted of a Released Inmates, % 60 crime 60 – Welfare Reform Act 50 45 Prohibited from receiving 40 food stamps or federal 30 assistance 30 – Reinstating Medicaid 20 coverage may be delayed 10 (average of 3 months) 0 Benefits affected by Housing Case Obtaining Substance Use duration of incarceration Management Medication Treatment Assistance Required1. Jordan AO, et al. Policy Brief — Enhancing linkages to HIV primary care and services in jail settings initiative: transitional care coordination — fromincarceration to the community. www.enhancelink.org/sites/hivjailstudy/Policy_brief_Transitional_Care_Coordination_Final_1.27.11.pdf. Accessed March 15,2012. 2. Wakeman SE, et al. HIV treatment in US prisons. www.medscape.com/viewarticle/725477. Accessed March 1, 2012.
One Simple Method to Reduce Treatment Interruptions Assisting HIV-infected inmates in filling out AIDS Drug Assistance Program (ADAP) forms (Texas) – Inmates who did not receive assistance filling out forms 5.4% filled prescriptions within 10 days after release 17.7% within the first 30 days 30% were still on therapy 60 days post-release – Inmates who had assistance filling out forms Twice as likely to fill their initial prescriptions within 30 days 33.6% were still on therapy 60 days post-releaseWhitten L. http://m.drugabuse.gov/news-events/nida-notes/2011/03/hiv-treatment-interruption-pervasive-after-release-texas-prisons. AccessedFebruary 29, 2012.
The VIBE Health Study:Interruptions in AntiretroviralTherapy (ART) are Common Following Release from Jail Robin A. Pollini 1, Daniel Lee 2, Ken Saragosa 2, Tim Smith 3, Josiah D. Rich 4, María Luisa Zúñiga 2 1) Pacific Institute for Research and Evaluation, Calverton, Maryland, USA; 2) School of Medicine, University of California San Diego (UCSD), San Diego, California, USA; 3) Health and Human Services Agency, County of San Diego, San Diego, California, USA; 4) Brown Medical School and Miriam Hospital, Providence, Rhode Island, USA
Background HIV prevalence in U.S. prisons and jails is four times that of the general population1 and 1 in 7 HIV+ persons in the U.S. passes through a criminal justice facility annually2 2009 JAMA study3 found that only 5% of HIV+ persons released from prison with a 10-day supply of ART filled their prescription within 10 days, and only 18% filled the prescription within 30 days.1. Maruschak 2009/10. http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf2. Spaulding AC, et al. HIV/AIDS among inmates of and relesees from US correctional facilities, 2006: declining share of epidemic but persistent public health opportunity. PLoS One. 2009;4(11):e7558.3. Saldana, J. (2009). The coding manual for qualitative researchers. Los Angeles, CA: SAGE.
Study Objective Our research team initiated the ViralInhibition through Better reEntry (VIBE)Study to better understand:– frequency and causes of post-release interruptions in ART among HIV+ persons leaving jail in San Diego County, California.
MethodsSetting: San Diego County operates 7 jailfacilities housing >5,000 inmates. HIV+inmates treated by UCSD physicians; HIV+inmates eligible for the County’s AIDS CaseManagement ProgramRecruitment: August 2010-October 2011Eligibility: 1) 18+ years old 2) released fromSD county jail in the last 30 days 3)notcurrently incarcerated 4) ever diagnosed withHIV 5) received HIV care during their lastincarceration
Methods (con.)Data Collection: Interviewer-administeredquantitative survey and a 1-hour qualitativeinterviewData analysis: descriptive statistics, regressionmodeling to identify factors independentlyassociated with ART discontinuity; qualitativeinterview summaries coded using descriptivecoding 3,4 to identify references to ART discontinuityand its contributing factors63 HIV+ recently-released individuals wereenrolled in the study
Results: ART Continuity After Jail ReleaseOf the 38 participants on ART at the timeof release23 (61%) missed at least one doseimmediately following their release(average number of days = 4)
Days of missed ART dosesimmediately after jail release (N=38)
Results (cont.): Survey resultsMost commonly cited reason for misseddoses while in jail: need for HIV physicianto prescribe medications afterincarcerationOther reasons: unavailability ofparticipant’s full ART regimen, provision ofincorrect drugs or dosages, not wanting togo to HIV clinic for fear of HIV+identification
Survey results: Reasons for missing ART doses after jail release (N=23) %Didn’t have the medications 87Couldn’t pay for the medications 26Was using drugs or alcohol 9Had medications but couldn’t get to them when needed 4 Top priority for participants who missed ART doses immediately after release (N=23) % Get drug or alcohol treatment 35 Find housing 22 Get cash 17 Reunite with family, partner or friends 9 Take care of legal problems 4 Use drugs or alcohol 4 Get HIV care/medications 4 Get identification 4
Comparing those who missed dosesafter jail release to those who did not:Missing ART doses was significantly associated with individuals who were younger, who used transportation from treatment facilities or used public transportation, and reported post-release methamphetamine use
Results: In-depth interviewsBarriers to post-release ART missed doses included: Expiration of MediCal and/or AIDS Drug Assistance Program (ADAP) coverage Logistical issues: medications not delivered to drug treatment facility, lack of transportation
ConclusionsA majority of VIBE Study participantsmissed ART doses immediately followingjail release.Factors such as discontinued medicalinsurance played a roleParticipants reported competingpriorities/demands: substance abusetreatment, housing, cash, etc.
CQI Project at SDCJIdentifying needs of SDCJ– Many opportunities for improvements exist– Needs identified by administration Lack of HIV specialty care – Driven by concern for lawsuits – Disinterest by jail doctors to assume care of HIV inmates– Needs identified by consultant/care provider Improve HIV-related care at SDCJ – HAART initiation, management – Diagnose/manage HIV specific conditions including OIs – Post-exposure prophylaxis and HIV post-test counseling
CQI Project at SDCJPlanning and implementing interventions(buy-in) to address needs– Not too difficult as long as interventions were “simple, cost-effective, and prevent lawsuits” Simple = minimal disruption to nursing staff and officers Cost-effective = not costing too much extra or breaking the budget Prevent complaints/lawsuits (unstated) – likely true though
Administrative Obstacles Obstacle Intervention Outcome Provide consultation and Continued improvement1. Lack of HIV specialty care direct HIV care of HIV care No intervention yet. No change, but lead by2. Disinterest of physicians Consider more education example No intervention yet. No change, but lead by3. Disinterest of nursing staff Consider more education example No intervention yet. No change, but lead by4. Disinterest of officers Consider more education example Some education provided Some improvement of5. Disinterest of pharmacists through direct interaction identification of errors No restriction on use of Perceived high costs of HIV Education of cost and HAART, but less difficulty6. drugs (use of generic risk/benefit of HAART and w/obtaining resistance drugs?)/resistance testing resistance testing testing now
HIV Medical Care Obstacles Obstacle Intervention Outcome Delay in initiating/resuming Usually started within a1. None, seen by intake MD HAART few days, w/exceptions Weekly review of all HIV Less medication errors,2. HIV medication errors meds for all SDCJ but disincentive for jail inmates staff to learn Inmates may refuse to3. None No change come to clinic due to stigma Discharge inmates with HIV Discussion with nurses Variable and dependent4. medications emphasizing importance on discharge RN & MD Work with transitional Improved transition of Inmates lost to followup on case managers to place care back with their HIV5. discharge, high recidivism inmates in drug rehab primary care provider, rates programs/placement decreased recidivism Implemented VIBE study Identified gaps in the Transitional care upon6. to look at transitional area of discharging release from jail care inmates with HIV meds
Number of Inmates 0 5 10 15 20 25 30 35 40 45 1/15/2008 2/15/2008 3/15/2008 4/15/2008 5/15/2008 6/15/2008 7/15/2008 8/15/2008 9/15/2008 10/15/2008 11/15/2008 12/15/2008 1/15/2009 2/15/2009 3/15/2009 4/15/2009 5/15/2009 6/15/2009 7/15/2009Week 8/15/2009 9/15/2009 10/15/2009 11/15/2009 12/15/2009 1/15/2010 2/15/2010 3/15/2010 4/15/2010 5/15/2010 6/15/2010 7/15/2010 HIV+ Inmates in San Diego County Jails 8/15/2010 9/15/2010 10/15/2010 11/15/2010 VDF FAC8 SDCJ LCDF GBDF EMDF Total #
Number of Errors 0 1 2 3 4 1.5 2.5 3.5 4.5 0.5 1/15/2008 2/15/2008 3/15/2008 4/15/2008 5/15/2008 6/15/2008 7/15/2008 8/15/2008 9/15/2008 10/15/2008 11/15/2008 12/15/2008 1/15/2009 2/15/2009 3/15/2009 4/15/2009 5/15/2009 6/15/2009 7/15/2009Week 8/15/2009 9/15/2009 10/15/2009 11/15/2009 12/15/2009 1/15/2010 2/15/2010 3/15/2010 4/15/2010 5/15/2010 6/15/2010 7/15/2010 ARV Prescription Errors in San Diego County Jails 8/15/2010 9/15/2010 10/15/2010 11/15/2010 Errors
ARV Medication ErrorsTotal of 86 errors over 126 weeks of ARV review– from 83 providers (37 unique providers)– 3 providers with 2 different errorsErrors per week– Mean = 0.68 errors/weekRange = 0-4 errors/weekErrors per provider– Median = 1 error/week– Range = 1-9 errors– 16 providers with 2 or more errors
ARV Medication Errors Type of Errors:1 Less than 3 ARV drugs 302 Incorrect dose of ARV drug 373 Incorrect frequency of ARV drug 94 ARV interaction 15 MD error (ie. Zerit instead of Zestril) 56 Missing Ritonavir as a Booster PI 17 Missing PI with Ritonavir 18 Too many ARV agents 19 Written for same drug twice 1
Summary and Future DirectionsMany opportunities exist for continuedimprovement in the delivery of quality HIV carein inmates at SDCJ – Has been successful in some areas – Require buy-in and support of administration and all those involved in careFuture directions – Continue multi-pronged CQI projects – Continue providing education and developing rapport and collaborations with those interested in HIV care
AcknowledgmentsColleagues who have shared Emergency Departmentthe burden of work at the jail Physicians– Chris Mathews – Ted Chan– Theo Katsivas – Gary Vilke– Alfredo Tiu– Tyler Lonergan SDCJ StaffTransitional Case Managers – Earl Goldstein– Rafaela Jennings – Sue Smith– Sonja Proctor – Terry Zakosky– Amy Applebaum – Chris McClean– Tim Smith SDCJ Pharmacy StaffVIBE Study Staff – Jeffrey Crutchfield– Robin Pollini – Ashley Clark– Mari Zuniga – Ida Bleich– Ken Saragosa– Serena Ruiz