HIV CARE IN CORRECTIONS
Douglas G. Fish, MD
Head, Division of HIV Medicine
Albany Medical College
New York/Virgin Islands
AIDS Education and Training Center
NY/VI AETC
Objectives
• Review basic epidemiology of HIV in prisons• Describe model of HIV care in NYS prisons• Describe HIV education/model programs to target
corrections healthcare providers• Review potential barriers to care in prisons and on
release back to community
NY/VI AETC
Prison Facilities
• Federal Prisons• State Departments of Corrections• NYC Department of Corrections • City/County Jails• Juvenile Detention Centers
NY/VI AETC
Percent of General Population & Inmate Population with AIDS
0
0.1
0.2
0.3
0.4
0.5
0.6
GeneralPopulationInmatePopulation
Bureau of Justice Statistics, 1998
Per
cen
t
NY/VI AETC
Percent of Inmates Known to be HIV+ in 1998
0
2
4
6
8
10
12
Per
cen
t
2.21.0
2.3
6.3
10.7
3.4
Bureau of Justice Statistics, 1998
NY/VI AETC
Epidemiology - New York State
• 71,000 inmates• Average length of stay: 39 months• 1.9 billion dollar budget
Albany Times Union, 11/12/00
NY/VI AETC
Epidemiology - HIV in Prisons
• Minority populations over-represented• 88% of AIDS cases in NYS DOCS occur in Blacks or
Hispanics• 85% of HIV infected in NYS have IDU as risk factor
AIDS in NY State; NYSDOH, 1996 edition
NY/VI AETC
Epidemiology - New York State
• 10% estimated HIV seroprevalence in NYS DOCS male facilities
• 25% estimated HIV seroprevalence in NYS DOCS female facilities
• HIV testing offered; not mandatory in NYS• Common to have AIDS-defining sentinel event as
prompt for testing
NY/VI AETC
Percent of State Prison Inmates Known to be HIV+ in 1998, by Sex
0
5
10
15
20
25
30
Total Northeast New York New Jersey
MaleFemale
Bureau of Justice Statistics, 1998
Per
cen
t
NY/VI AETC
Northeast New York Region
• Includes 3 Hubs• 12 clinics/mo on-site at Coxsackie Correctional
Facility; 5 faculty• HIV subspecialty care• Coxsackie regional medical unit (RMU)• Hospitalization at Albany Medical Center
– locked unit with typical patient rooms
NY/VI AETC
NY/VI AETC
NY/VI AETC
HIV Continuity of Care
• Primary care is via facility medical staff• We follow HIV care guidelines of AIDS Institute for
subspecialty care• Hour for new patients; 30 minutes for follow-ups• Recommend time interval for follow-up• Correctional managed care role
NY/VI AETC
HIV Continuity of Care
• Telemedicine available for follow-up visits via PictureTel
• Phone follow-up; facsimile• Require dictated discharge summaries for hospital
discharges
NY/VI AETC
HIV Education
• Numerous conferences/lectures– didactic– case presentations
• PictureTel for case presentations– 1 to 4 facilities at a time– best if facility staff bring cases– topic discussions, as well
NY/VI AETC
NY/VI AETC
HIV Education
• Clinical consultations– most use is between 8-5:00– 24 hour availablity via answering service– calls come mostly from within our region
• Satellite videoconferences– three per year– Jan 30, 2001: HIV Primary Care– 3 topics and 1 case discussion, with call-in Q&A
NY/VI AETC
HIV Education
• CD-ROM virtual clinic • Piloting at local county jails• 8 hour program, offering simulated teaching
experience in longitudinal HIV care• Tailored to individual use, so ideal for practitioners
who are isolated
NY/VI AETC
Inmate Adherence Video Series
• 5-part video set, 15-30 minutes each• Focus group developed core concepts• HIV-infected former inmates
– tell their stories in peer group setting• Medical component - physician and nurse
NY/VI AETC
Inmate Adherence Video Series
• Living Well with HIV: Coping with a Positive Diagnosis
• Fighting Back: Understanding the HIV Lifecycle• Making the Choice: ART 101 & Therapy for Life
NY/VI AETC
Inmate Adherence Video Series
• Staying the Course: Staying on Antiretroviral Therapy Once You have Started
• Taking Charge
NY/VI AETC
Inmate Adherence Video Series
• Collaborative Effort:– New York State DOCS– Private pharmaceutical industry– Albany Medical College’s Div. of HIV Medicine
NY/VI AETC
Goals: Adherence Video Series
• Standardize message to those HIV-infected• Administer pre- and post- Likert-style questionnaire
with each video– e.g. “People can live well with HIV.”– best with a facilitator– Spanish and English versions available
• Education days throughout Upstate DOCS facilities to train on implementation
NY/VI AETC
Video Projects in Development
• HIV in Women• Spanish Video Series
– with support from NYSDOH AIDS Institute• prevention,getting tested, early intervention• treatment, adherence
NY/VI AETC
Barriers to HIV Care - 3 Ps
• Prison level• Provider level• Patient level
NY/VI AETC
Prison level
• Security is top priority• Must operate within confines of daily life
– daily counts several times a day– lockdowns
• Geographic isolation• Frequent inmate transfers
NY/VI AETC
Provider Level
• Large numbers of inmates presenting to sick call• Significant variety in HIV experience and comfort
level of providers• Distinguishing medical need from secondary gain• Professional & geographic isolation• Cultural differences
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Provider Level - Medications
• Rapidly expanding HIV formulary and treatment guidelines
• Keep-on-person (KOP) vs. directly observed• Liquid formulations• Refrigeration needs of some medications
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Patient Level
• HIV stigma• Reluctance to test for fear of labeling• Mistrust of system/authority/medical• Language/cultural barriers• Confidentiality concerns
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Patient Level
• Prior negative experience with health care• Attitude
– “I’ll take care of it when I get out”• Addictions• Fears
– antiretrovirals– “experimentation”
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Opportunities if HIV Status Unknown
• HIV education• Risk factors; transmission• Offer testing• HIV prevention• Names reporting; partner notification
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Opportunities if HIV-Infected
• Education about HIV• Explanation of immune system; T-cells• Explanation of viral load• HIV as chronic illness model
NY/VI AETC
Opportunities if HIV-Infected
• Utility of antiretroviral therapy• Utility of prophylaxis of opportunistic infections• Importance of adherence• Value of peer advocacy
– “someone to talk to”
NY/VI AETC
Opportunities if HIV-Infected
• Importance of staying clean; treatment program if substance use history
• Importance of regular medical follow-up, even if does not need treatment now, or chooses not to receive it
• Empower inmate with sense of control about his/her illness
NY/VI AETC
Our Experience
• Spending the time to develop some trust• Inmates typically appreciative• Often their first experience at taking their health
seriously• Respecting/listening to their concerns, even if about
things we can’t change• Few holdouts, but may take months
NY/VI AETC
Clinical Research in Prisons
• More patient protections for this vulnerable population• No placebo-controlled trials• Prison advocate sits on Institutional Review Board
(IRB)• Protocol must be open to non-prison population, as
well• Informed consent strictly adhered
NY/VI AETC
Pre-release Planning
• Start several months prior to release• Community-based organizations (CBOs) can be
enormous help with plan• Peer advocates• Best if a clinic/office can be identified, and an actual
appointment made• Identify potential barriers
NY/VI AETC
Potential Barriers
• 80% of NYS inmates in Upstate facilities return to NYC to live
• Discharge planners may be unfamiliar with systems, providers in NYC
• Large geographic barriers• Funding and staffing constraints of all organizations
involved
NY/VI AETC
Potential Barriers
• Transportation• Directions - knowing where to go• Language, culture• Communication of plans with inmate• Barriers will vary depending on destination
– urban vs. rural, as example
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Other Considerations
• Healthcare may not be the most pressing concern for the inmate on discharge– housing, food, job, acclimating
• Lack of support systems “back at home”– home may be a chaotic place– families may be out of state or overseas– inmate may not have family
NY/VI AETC
Inmate /Patient Needs on Release
• Food and housing• Medications or means to obtain them• Medical coverage - ADAP available in NYS• Contact number if having problems• Medical follow-up, preferably an appt.• Link to aftercare if substance use history
NY/VI AETC
Community Provider Needs
• Patience• Awareness of urgent needs of patient
– medications– intercurrent illness– case management
• Medical records; summary• Interpreter, if necessary
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Most Effective Tools
• Good communication with inmate of plans• Assessment of inmate’s understanding of plan• Strong link with CBO; identified contact person• Peer advocates, both in prison and out
NY/VI AETC
City/County Jails
• Very high turnover• Medical units often understaffed• Limited discharge planning
– often very little warning of release– med. liability cov. may not extend beyond jail
• Increasing privitization– help put some policies/procedures into place– for profit
NY/VI AETC
Summary
• Medical care delivery in prisons is complex• Many challenges and opportunities• Barriers are not insurmountable• AETCs can play major role in providing training to
providers• Many rewards in prison health, and efforts are
appreciated by inmate pts/clients
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