D.C. Department of Corrections COMMUNITY-ORIENTED CORRECTIONAL HEALTH CARE: HIV TESTING AND

1. 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

2. 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.

3. Community-Oriented Correctional Health Care Model (COCHC) • Based on the 5 elements of the Public Health Care Model: 1. Early detection and assessment 2. Prompt and effective treatment at a community standard of care3. Prevention measures 4. Comprehensive health education5. 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 • Incorporate linkages during incarceration and upon re-entry. • Goal is to promote continuity of care that will improve public health and safety outcomes.

4. Electronic Medical Record(EMR) • The DOC is the only regional facility where inmate medical recordsareelectronic. • 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.

5. Discharge Planning Discharge planning begins at intake into the correctional facility and ends with successful inmate linkages to community support systems upon re- entry 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.

6. Initial Discharge Treatment Plan (IDTP) • Discharge planning begins at intake. • Created by medical provider performing the H&P • Includes: • 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.

7. 528 28 275 50 86 36 282 HIV, Mental Illness & Substance Abuse in Inmates Total Inmates = 3184 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

8. HIV Testing • 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. • DirectorBrown’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.

9. HIV Inmates Total Inmates Incarcerated with HIV/AIDS: 202 or 6.4% of 3,147 Total Inmate Population on August 20, 2009.

10. DOC HIV Oral Rapid ResultsAll data collected from the D.C. Department of Corrections Electronic Medical RecordOctober 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] • Negative Oral Rapid Results= 8,404 [99% Total Intakes] • Positive Oral Rapid Results= 67 [<1% of Rapid Tests] • Oral Rapid Test Results (False Positive)= 8 or [<1% of Rapid Tests] • Incomplete Confirmation= 8 or [<1% of Rapid Tests]

11. 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 Pre-Test 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.

12. 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.

13. 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.

14. 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. • 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.

15. HIV Testing in the DOC (con’t) • 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.

16. Opt-out/Refusals/Declines Reasons: • 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.

17. Condom Distribution Program: • 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 . • 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. • The DOC updated internal policy includes specific procedures governing the issuance of condoms to inmates. • Medical offers condoms following HIV testing. • For anonymity, no documentation is made of the request. Unity tracks condom distribution without documentation of specific inmate use. • The DOH provided more than 10,000 condoms at no cost to the DOC.