HIV and Corrections—An International Perspective

1. HIV and Corrections—An International Perspective David Farabee, Ph.D. Department of Psychiatry & Biobehavioral Sciences University of California, Los Angeles

2. World Map

3. Annual Reports of New HIV/AIDS Cases in Taiwan

4. Diffusion of HIV Among IDUs HIV Prevalence Rate (%) Stimson (1996)

5. Vectors of HIV Transmission for General and Correctional Populations Dean-Gaitor & Fleming (2000) UCLA-ISAP

6. Methamphetamine & HIV

7. Injection-Related HIV Risk • Injected in the Past 6 Months: • MA Users: 37.1% • Non-MA Users: 1.1% • Of these— • 24% used “dirty” syringes • 30% shared cookers, rinse water, etc. Farabee et al., 2002 UCLA-ISAP

8. Sex-Related HIV Risk (Odd Ratios of MA Users vs. Non-MA Users) UCLA-ISAP

9. Sex-Related HIV Risk (Comparing MA Users vs Non-MA Users)

10. Prevention Opportunities in the Criminal Justice System • The prevalence of HIV infection in the U.S. is > 5 times higher among state prison inmates (1.9%) than for the general population (0.37%) (Maruschak, 2006) • IDUs who pass through the CJS are no more likely than non-arrested IDUs to have ever been tested or given harm-reduction materials/information (Farabee et al., 2002) UCLA-ISAP

11. Domains of Harm Reduction Institutional Post-release

12. Harm Reduction in the Institution

13. Provision of Bleach & Syringes • Syringes not available in any U.S. correctional system; bleach offered in 2 U.S. jails. • Several European prison systems offer syringes; bleach is offered in about half (of 20 surveyed). Kantor, (2003) UCLA-ISAP

14. The Hindlebank Experiment UCLA-ISAP

15. Distribution of Condoms • Available in less than 1% of US jails and prisons (May & Williams, 2002) • WHO survey found that 23 of 52 systems surveyed have distributed condoms since 1991 • None has reversed this policy (Kantor, 2003; WHO, 1992) • In Canada, 10% of staff reported condoms posed a problem, primarily due to their use as water balloons (Kantor, 2003) UCLA-ISAP

16. Harm Reduction Following Release Secondary risk prevention Medication adherence

17. Secondary Risk Prevention

18. Do Prevention Interventions Reduce HIV Risk among HIV+ People ? • Crepaz et al. (2006) meta-analysis: • Studies published from 1988-2004 • 12 met inclusion criteria • Must have at least 3-month behavioral/ biological outcomes

19. Meta-Analysis Results

20. Critical Elements of Effective Interventions • Specifically designed to change HIV transmission behaviors • Delivered by health care professionals • Delivered to individuals • Intensive (# sessions/duration) • Delivered in settings where PLWH receive routine care

21. Medication Adherence After Release

22. CD4 Lymphocyte Counts by Incarceration Status Stephenson et al. 2005

23. Released Inmates Filling ART Prescriptions • Undetectable viral load • Released to community supervision • Received pre-release planning/linkages Baillargeon et al. 2009

24. Strategies for Improving Adherence • Behavioral interventions (Kripalani et al., 2007) • Dosing • Modified supervision requirements • Designated guardian (Farabee et al., 2002) • OST platforms (Moatti et al., 2000)

25. Summary & Conclusions • IDU role in the spread of HIV is especially prominent in corrections • Other drugs (MA) also show a strong relationship • The CJS is a critical point of contact for HIV prevention and treatment, but underused

26. Summary & Conclusions • Prison-based harm-reduction approaches tend to be viewed positively and are rarely rescinded • Secondary prevention interventions can reduce odds of unprotected sex (OR=.57) and STD acquisition (OR=.20) • Post-release HAART adherence is a problem

27. Summary & Conclusions • Behavioral interventions, designated “guardians,” and OST (methadone, buprenorphine) platforms significantly improve adherence rates in the community.