Download - HIV & Jails: A Public Health Opportunity
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HIV and Jails: A Public Health Opportunity September 19, 2013
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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
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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
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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
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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
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Outline:
•Introduction (brief) to U.S. Correctional System
•Epidemiology of Health / Corrections
•Public Health and Public Safety
•Linkages: Continuity of Care
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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.
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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
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10
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Criminal Justice System
•Law enforcement ▫ Police, sheriff, highway patrol, FBI, etc.
•Adjudication ▫ Courts
•Corrections ▫ Jails, prisons, probation and parole
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Types of Correctional Supervision
•Probation
•Jail Custody
•Prison Custody
•Parole
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Distribution of Population
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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
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Why Jails? Over 95% of persons released from correctional facilities leave jails!
Annual Admissions Average Daily Population
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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
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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%
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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
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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
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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
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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
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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
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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.
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Cycle of Incarceration
Community JailCourt
Prison
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Relationships in the Community
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When Prison Enters the Picture
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Concurrent Relationships in the
Community
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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
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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.
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The Collaboration: Culture of Corrections
•Working within/inside a Correctional Setting
•Working with the Correctional System
•Patience & Persistence….
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Issues to Consider
• Disconnect between Corrections and Public Health
• Different Cultural Identities
• Security= Safety First
• Operational Policies, Procedures and Relationships
• Confidentiality
• Ethical Considerations
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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
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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
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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
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Project START for People with HIV•RCT
▫Individual and Ecosystem▫Jail and Prison
•Medication use•Medication adherence•Recidivism
•Sexual behavior
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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
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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.
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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
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In Conclusion:
•The jail setting represents access to a population to improve community health.
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Thank you….
For more information:
•www.thebridginggroup.com
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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
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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
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Enhance Link Care Sites and Partners
Evaluation and Support Center: Emory University/Abt Associates
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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
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• 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
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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
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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??
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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
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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?
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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?
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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?
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HOW DID EMORY/AID ATLANTA SUSTIN PROGRAM AT FULTON COUNTY (GA) JAIL
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RE-ESTABLISHMENT OF RAPID TESTINGCONTINUED LINKAGE SERVICES
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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?
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CHALLENGES OF TRANSFERRING INFORMATION
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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…
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HERE IS A TYPICAL MEDIUM SIZED JAIL:SPALDING COUNTY (GA)
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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
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Q&A
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