Transcript Devon Brown: The District of Columbia Department of Corrections' Automatic HIV Testing and Counseling Program

D.C. Department of Corrections
COMMUNITY-ORIENTED CORRECTIONAL HEALTH CARE: HIV TESTING AND
DISCHARGE PLANNING IN THE D.C. DEPARTMENT OF CORRECTIONS
Workshop to Identify Facilitators and Barriers to HIV Testing
Institute of Medicine Committee on HIV Screening and Access to Care
April 15, 2010
Devon Brown
Director, DOC
Presented by:
Henry R. Lesansky, PhD., CCM
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Leadership and Direction

In 2006, the District and the DOC changed its approach to health care service
delivery for its inmates. The Community-Oriented Correctional Health Care
Model (COCHC) was implemented, of which a version was successfully
implemented in Hampden County, Massachusetts in 1992.

The COCHC model encompasses all of the elements of the Public Health
Model and reflects our belief that the inmate is an integral part of the
community while incarcerated as well as when he/she returns to society at
release. Providing community linkages that support an inmate’s re-entry into
society will impact the individual’s health outcomes and recidivism rates
through continuity of care. The District and DOC strongly feel that regardless
of status--whether an inmate or a resident of the community--a person is more
likely to remain employed, productive, and law-abiding when his/her health
care concerns are being addressed with continuity of care available and
provided. The COCHC model assists in our goals of successful and sustained
inmate re-entry with improved public safety and public health outcomes.
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Community-Oriented Correctional
Health Care Model (COCHC)

Based on the 5 elements of the Public Health Care Model:
1.
2.
3.
4.
5.

Early detection and assessment
Prompt and effective treatment at a community standard of care
Prevention measures
Comprehensive health education
Discharge planning to encourage continuity of care in the community upon release
Incorporates comprehensive network of programs promoting
Education
 Prevention
 Treatment
 Referrals and Community Involvement

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Incorporate linkages during incarceration and upon re-entry.
Goal is to promote continuity of care that will improve public health and safety
outcomes.
3
Electronic Medical Record
(EMR)
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The DOC is the only regional facility where inmate
medical records are electronic.
The Electronic Medical Record (EMR) is called
Logician or Centricity.
The EMR system was implemented in February
1998.
Query and audit capability exist within the EMR.
Unity Health Care personnel and District agency
providers enter all data into each inmate’s record.
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Discharge Planning
Discharge planning begins at intake into the correctional facility and ends
with successful inmate linkages to community support systems upon reentry that promote:
 Access
to continuity of care.
 Promote
life-style changes that would result in decreased
recidivism and facilitate better community health and
safety outcomes.
5
Initial Discharge Treatment Plan
(IDTP)

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Discharge planning begins at intake.
Created by medical provider performing the H&P
Includes:


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diagnosis, medications, required follow-up, and
a list of community clinics in all 8 wards of the District.
Assists inmates in receiving community based
treatment if released within 24 hours after intake.
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HIV, Mental Illness & Substance Abuse in Inmates
Total Inmates = 3184
856 Inmates (25.8%)
abused alcohol
or drugs
528
28
86
200 Inmates (6.2%)
HIV positive
50
36
275
282
643 Inmates (20%)
were diagnosed
with Mental Illness
1924 Inmates (60.4%) had neither Substance Abuse nor Mental Illness Diagnoses nor HIV
1260 Inmates (39.6%) had either Substance Abuse or Mental Illness Diagnoses or HIV
More than 50% of HIV positive inmates have either been diagnosed with mental
illness or substance abuse now or in the past
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HIV Testing

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In 2006 the Mayor of D.C. implemented the city-wide
initiative in HIV testing. The DOC was already testing
upon request of the inmate.
Director Brown’s vision was to begin Automatic Testing,
making it a routine part of medical intake processing.
The DOC implemented automatic HIV testing in June
2006.
The inmate can be tested at:



Intake
Sick call and
Release.
8
HIV Inmates
Total Inmates Incarcerated with HIV/AIDS:
202 or 6.4% of 3,147 Total Inmate
Population on August 20, 2009.
9
DOC HIV Oral Rapid Results
All data collected from the D.C. Department of Corrections Electronic Medical Record
October 1, 2008-May 31, 2009
Total Inmates Tested in the DOC = 9,142
Tested at Intake=8471 (80%of total intakes)
Tested at Sick Call=449 (5% of total intakes)
Tested at Release=222 (2% of all intakes)
Total Intakes Conducted by Medical= 10,560

Confirmed positive thru serology=
58 or [<1% of the total tested

Confirmed Positive Newly Identified= 37 or [<1% of Rapid Tests and 64% of Confirmed Positives]

Confirmed Positive Previously/Self Reported = 21or [<1%of Rapid Tests and 36% Confirmed Positive]

Females confirmed positive=
8 or [<1% of Rapid Tests and 13% of Confirmed Positive]

Males confirmed positive=
50 or <1% of Rapid Tests and 86% of Confirmed Positives]
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Negative Oral Rapid Results= 8,404 [99% Total Intakes]
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Positive Oral Rapid Results= 67 [<1% of Rapid Tests]
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Oral Rapid Test Results (False Positive)= 8 or [<1% of Rapid Tests]
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Incomplete Confirmation=
8 or [<1% of Rapid Tests]
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Refusals/Not Tested for Other Reasons

Refusals:
1,040 or [10%] of all intakes that received Rapid Testing.
Although they refused the HIV test at intake, they received PreTest Counseling, which includes the importance of testing, and
practicing safe sex.

Not Tested for Other Reasons:
378 or [3%] of all intakes completed by Medical. This number
represents the intakes that were not tested for reasons other than
refusing. A small population may have been inadvertently missed
during the intake process. Some were already positive.
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Release Medications
January 2008, the DOC began issuing a thirty (30) day supply of
HIV related meds at the time of the inmates release. The DOC and
DOH believe this will allow an extended period of time for those
released to report to one of the many clinics in the District to
continue with their treatment.
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Report Card for the D.C. DOC
Automatic HIV Testing

The D.C. Appleseed Center for Law and
Justice, an advocacy group, gave the
Department of Corrections an “A” on its fifth
report card for responding to the District’s
HIV-AIDS epidemic. The DOC has
consistently received the highest grades in the
City over the last three years by the Appleseed
Center for its efforts in combating this illness.
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Testing in the DOC

Unity provides HIV counseling and testing service to inmates at the DOC
using the Ora-Quick Rapid Kits at intake, sick call and release.
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Inmate with preliminary positive result receives:
 an immediate referral for serological confirmatory testing and
 further counseling.

Inmates with negative results will receive post-test counseling.

Inmates can refuse to be tested, and are not subject to disciplinary action,
but is referred to a medical professional for further counseling. Inmates
may voluntarily seek testing at any point during their incarceration.

Unity ensures that inmates receive further counseling and confirmatory
serology testing prior to being housed.

Inmates who receive confirmation of a positive result receives a treatment
plan that includes: counseling, teaching, chronic care clinic appointments
meds if needed, mental health support and discharge planning.
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HIV Testing in the DOC (con’t)
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Oral HIV Rapid testing at intake-- the Fifth Vital Sign
Screening – the initial test (intake, sick call or release)
Informed consent – the communication between the
inmate and the provider
Pre/Post Counseling – risk assessment, recognizing and
identifying specific behaviors.
Linkages – inmate is connecting with services to address
prevention needs
Op-out/Refusal/Declines – the process of the inmate
refusing testing.
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Opt-out/Refusals/Declines
Reasons:
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Recently tested
Self –Reported Positive
Does not want to know their status
Knows their status
Not sexually active
No reason provided
75% of individuals that declined testing cited they were recently
tested in the community
15 % cited they did not want to know their status.
10% did not cite a reason for refusing
The follow-up for the inmates that refuse testing at intake is to counsel them
once they have separated from the intake processes to provide more
information, and address the reason for refusal.
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Condom Distribution Program:
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Utilizes community partners to support the DOC COCHC model’s goal of
improved outcomes in public health and safety.

Was implemented in the early 1990’s, one of the first in the country .
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The DOC policy strictly prohibits sexual activity among inmates. The HIV/AIDS
issue is considered more pernicious than the consequences resulting from inmates
committing consensual sex infractions.
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The DOC updated internal policy includes specific procedures governing the
issuance of condoms to inmates.
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Medical offers condoms following HIV testing.
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For anonymity, no documentation is made of the request. Unity tracks condom
distribution without documentation of specific inmate use.
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The DOH provided more than 10,000 condoms at no cost to the DOC.
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