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HIV CARE IN CORRECTIONS

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. Objectives. Review basic epidemiology of HIV in prisons Describe model of HIV care in NYS prisons

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HIV CARE IN CORRECTIONS

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  1. 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

  2. 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

  3. Prison Facilities • Federal Prisons • State Departments of Corrections • NYC Department of Corrections • City/County Jails • Juvenile Detention Centers

  4. Percent of General Population & Inmate Population with AIDS Percent Bureau of Justice Statistics, 1998

  5. Percent of Inmates Known to be HIV+ in 1998 10.7 6.3 Percent 3.4 2.3 2.2 1.0 Bureau of Justice Statistics, 1998

  6. Epidemiology - New York State • 71,000 inmates • Average length of stay: 39 months • 1.9 billion dollar budget Albany Times Union, 11/12/00

  7. 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

  8. 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

  9. Percent of State Prison Inmates Known to be HIV+ in 1998, by Sex Percent Bureau of Justice Statistics, 1998

  10. 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

  11. 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

  12. HIV Continuity of Care • Telemedicine available for follow-up visits via PictureTel • Phone follow-up; facsimile • Require dictated discharge summaries for hospital discharges

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Inmate Adherence Video Series • Staying the Course: Staying on Antiretroviral Therapy Once You have Started • Taking Charge

  19. Inmate Adherence Video Series • Collaborative Effort: • New York State DOCS • Private pharmaceutical industry • Albany Medical College’s Div. of HIV Medicine

  20. 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

  21. Video Projects in Development • HIV in Women • Spanish Video Series • with support from NYSDOH AIDS Institute • prevention,getting tested, early intervention • treatment, adherence

  22. Barriers to HIV Care - 3 Ps • Prison level • Provider level • Patient level

  23. 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

  24. 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

  25. Provider Level - Medications • Rapidly expanding HIV formulary and treatment guidelines • Keep-on-person (KOP) vs. directly observed • Liquid formulations • Refrigeration needs of some medications

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

  27. Patient Level • Prior negative experience with health care • Attitude • “I’ll take care of it when I get out” • Addictions • Fears • antiretrovirals • “experimentation”

  28. Opportunities if HIV Status Unknown • HIV education • Risk factors; transmission • Offer testing • HIV prevention • Names reporting; partner notification

  29. Opportunities if HIV-Infected • Education about HIV • Explanation of immune system; T-cells • Explanation of viral load • HIV as chronic illness model

  30. 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”

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. Community Provider Needs • Patience • Awareness of urgent needs of patient • medications • intercurrent illness • case management • Medical records; summary • Interpreter, if necessary

  40. 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

  41. 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

  42. 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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