HIV and Jails: A Public Health Opportunity September 19, 2013

Agenda

Introduction to SPNS Integrating HIV Innovative Practices (IHIP) projectSarah Cook-Raymond, Impact

Marketing + Communications

Presentations fromBarry Zack, The Bridging GroupDr. 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

4.15.5

17

1113

02

46

810

1214

1618

HIV AIDS HCV TB MentalIllness

Fold

Incr

ease

in P

reva

lenc

e

HIV prevalence (%) in selected countries

0

5

10

15

20

25

30

35

40

45

Canada Brazil USA Honduras Spain RF Vietnam Indonesia Ukraine SouthAfrica

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 2006At 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 JailCourt

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 to a population to improve community health

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 servicesTreatment

ID (HIV, HCV, STIs, HBV, etc.)Chronic (hypertension, diabetes)Substance Use & Mental Health

Adequate community resourcesAddressing 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 LearnedAnne Spaulding MD MPH—Emory University, Atlanta Georgia PI, EnhanceLink Evaluation and Support Center

Funder: HRSADates: September 2006 – August 2012Number of Sites: 10; Number of Jails Served: 20Cost: $22 Million

Major Activities: HIV Testing & Continuity of Care Programs

Enrollment Jail DischargeSix Months

Post-Release

Discharge Planning Intensive Case Management

Court AdvocacyBasic 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 KnownHIV + (n=27,827)Previously KnownHIV + (n=27,827)

Offered Transitional LinkageServices (n=9,837)

Offered Transitional LinkageServices (n=9,837)

Newly DiagnosedHIV + (n=822)

Newly DiagnosedHIV + (n=822)

Sum of instances when HIV+ persons known to be in

jail = 28,649

Enrolled in Client Level Portion ofMulti-Site Evaluation (n=1,386)

Enrolled in Client Level Portion ofMulti-Site Evaluation (n=1,386)

Enrolled in TransitionalLinkage Services (n=8,056)

Enrolled in TransitionalLinkage 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 BEHAVIORSPECIAL 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??

Poll1. 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

Poll1. 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?

Poll1. 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?

Poll1. 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 TESTINGCONTINUED LINKAGE SERVICES

Poll1. 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

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