hiv care in corrections douglas g. fish, md head, division of hiv medicine albany medical college...

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

NY/VI AETC

Provider Level - Medications

• Rapidly expanding HIV formulary and treatment guidelines

• Keep-on-person (KOP) vs. directly observed• Liquid formulations• Refrigeration needs of some medications

NY/VI AETC

Patient Level

• HIV stigma• Reluctance to test for fear of labeling• Mistrust of system/authority/medical• Language/cultural barriers• Confidentiality concerns

NY/VI AETC

Patient Level

• Prior negative experience with health care• Attitude

– “I’ll take care of it when I get out”• Addictions• Fears

– antiretrovirals– “experimentation”

NY/VI AETC

Opportunities if HIV Status Unknown

• HIV education• Risk factors; transmission• Offer testing• HIV prevention• Names reporting; partner notification

NY/VI AETC

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

NY/VI AETC

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

NY/VI AETC

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