Transcript HIV and Jails: A Public Health Opportunity September 19, 2013 Agenda  Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project  Sarah Cook-Raymond, Impact Marketing + Communications 

HIV and Jails: A Public Health
Opportunity
September 19, 2013
Agenda
 Introduction
to SPNS Integrating HIV
Innovative Practices (IHIP) project
 Sarah
Cook-Raymond, Impact Marketing +
Communications
 Presentations
 Barry
from
Zack, The Bridging Group
 Dr. Anne Spaulding, Emory University
Q
&A
IHIP Resources on
TARGET Center Website
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
The Bridging Group
September 19th, 2013
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
Prisons
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.
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
Fold Increase in Prevalence
Prevalence of Various Conditions
Compared to General US Population
18
16
14
12
10
8
6
4
2
0
17
13
11
5.5
4.1
HIV
AIDS
HCV
TB
Mental
Illness
HIV prevalence (%) in selected
countries
45
40
35
30
25
Adults
Prisoners
20
15
10
5
0
Canada
Brazil
USA
Honduras
Spain
RF
Vietnam Indonesia Ukraine
South
Africa
HIV Prevalence Among Those
Released From Prison/Jail in 2006
14.1
85.9
 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 2006
 At 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.
HIV Prevalence in the 12 City Jails:
Metropolitan Statistical
Area
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
Average
Daily Jail
Population
Estimated HIV Prevalence Rates
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.
2. Hammett TM. Am J Pub Health. 2006;96(6):974-978.
3. Davies R. Lancet. 2004:364:317-318.
4. Stephens TT et al. Am J Health Stud. 2005.
Cycle of Incarceration
Court
Community
Jail
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

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

Mission = Public Health
Orientation toward Change
Humanitarian
Dress code is (more) Informal
Prevention/Screening/Care
Client/Community-Centered
Flexibility
Creative
Jail & Prison
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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:
Incarceration
Freedom
What are we doing?
Making the transition work!
Screening
Diagnosis
– Infectious diseases (HIV, STI, TB, HCV,
HBV)
– Mental illness
– Substance abuse
 Treatment
 Pre-release planning
 Linkage to care and services
Treatment
ID (HIV, HCV, STIs, HBV, etc.)
Chronic (hypertension, diabetes)
Substance Use & Mental Health
 Adequate community resources
Addressing life’s competing priorities
Reincarceration
How to break the cycle?
 Societal
challenge (poverty, discrimination, etc.)
 Policy (Sentencing, Drugs, Housing, Sex Offenders)
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
• [email protected]
EnhanceLink Initiative to Link HIV+
Jail Releasees to Community Care –
A Legacy of Lessons Learned
Anne Spaulding MD MPH—Emory University, Atlanta Georgia
PI, EnhanceLink Evaluation and Support Center
Funder: HRSA
Dates: September 2006 – August 2012
Number of Sites: 10; Number of Jails Served: 20
Cost: $22 Million
Major Activities: HIV Testing & Continuity of
Care Programs
TESTING
Jail Discharge
Enrollment
Discharge Planning
Court Advocacy
Housing
L
I
N
K
A
G
E
Six Months
Post-Release
Intensive Case Management
Health, HIV
care & Social
Service Needs
Basic Needs like
Transportation
Enhance Link Care Sites and Partners
Evaluation and Support Center: Emory University/Abt Associates
EnhanceLink Study Population Admission, Testing & Service Events
Jail Admission
(n=877,119)
Offered HIV Testing
(n=499,131)
Tested for HIV
(n=210,267)
HIV-positive Test Result
(n=1,312)
Newly Diagnosed
HIV + (n=822)
Previously Known
HIV + (n=27,827)
Sum of instances when HIV+
persons known to be in
jail = 28,649
Offered Transitional Linkage
Services (n=9,837)
Enrolled in Transitional
Linkage Services (n=8,056)
Enrolled in Client Level Portion of
Multi-Site Evaluation (n=1,386)
AIDS AND BEHAVIOR
SPECIAL ISSUE
• 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
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 costeffective from a societal perspective
• But we had to extrapolate from other studies
• How many participants would have linked even without
EnhanceLink??
Poll
1. 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?
Poll
1. 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?
Poll
1. 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?
Poll
1. 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 TESTING
CONTINUED LINKAGE SERVICES
Poll
1. 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
Must keep in mind…
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
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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sign up for the IHIP listserv by emailing [email protected].
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