Transitioning Correctional Patients into the Clinic

1. Transitioning CorrectionalPatients into the Clinic Ernesto J. Lamadrid, MD, AAHIVS Faculty, Florida/Caribbean AETC

2. Disclosures of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This speaker will not discuss any off-label use or investigational product during the program. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

3. Why Care About the Health of Inmates? • Those who have been incarcerated • 25% of HIV-infected Americans • 33% of Americans infected with hepatitis C virus (HCV) • 40% of Americans with active tuberculosis • Among inmates • Up to 50% have axis 1 or 2 mental disorders • As many as 75% have alcohol and/or other substance abuse disorders Hammett TM, et al. Am J Public Health. 2002;92:1789-1794.

4. Only the Incarcerated Have a Legal Right to Healthcare • “The public be required to care for the prisoner who cannot by reason of the deprivation of his liberty, care for himself.” • Spicer vs Williams 191 NC 1926 • Deliberate indifference to serious medical needs of the prisoners is a violation of the 8th amendment • Supreme Court 1976

5. Comorbid Conditions in the Incarcerated Population • Mental illness • Substance abuse • Tuberculosis • Sexually Transmitted Diseases (STDs) • Hepatitis, especially HCV • 1.3 to 1.4 million inmates are HCV+ • Prevalence of HCV in inmates 10x that of U.S. population • Incarcerated women have a higher rate of HCV than incarcerated men DeGroot A. HEPP News. April 2001; Baillargeon J, et al. Public Health. 2003;117:43-48.

6. EPIDEMIOLOGY

7. State or Federal Prison Inmates Reported to be HIV Positive or to have Confirmed AIDS, 2006-2008 Maruschak, L: HIV in Prisons, 2007-08 December 2009, NCJ 228307

8. Year End 2008 Prison Statistics • In 2010, 72 inmates in state prisons and seven in federal prisons died from AIDS-related causes. AIDS-related deaths among all state and federal prisoners dropped from 24 deaths per 100,000 inmates in 2001 to five per 100,000 in 2010 • Among all inmates with HIV/AIDS, the AIDS-related death rate dropped on average about 13 percent each year, from 134 deaths per 10,000 inmates with HIV/AIDS in 2001 to 38 per 10,000 in 2010. • In 2010, the estimated rate of HIV/AIDS among state and federal prisoners dropped to 146 cases per 10,000 inmates from 194 cases per 10,000 in 2001. • The number of male inmates in state or federal prisons who had HIV/AIDS declined from 19,027 at year end 2009 to 18,337 at year end 2010, while the number of females who had HIV/AIDS decreased from 1,853 to 1,756 over the one-year period. Maruschak, L: HIV in Prisons, 2007-08 December 2009, NCJ 228307

9. HIV EDUCATION AND TESTING IN PRISONS

10. Opportunities • Clustering of individuals with many healthcare needs • Opportunity for directly observed therapy • Teachable moment? • Constitutional right to healthcare • Court mandated resources • Diagnosis • Education • Prevention of complications • Management of comorbid illnesses • Treatment access • Prevention of transmission

11. Florida Law for HIV Testing in State Prisons • Florida Law requires that inmates be tested for HIV [FLA. STAT. §945.355 (2008)]: • At least sixty days prior to release unless an inmate’s HIV status is already known. Inmates who have been tested within a year prior to their presumptive release date are only tested upon request. • When there is evidence that an inmate has engaged in behavior that places him or her at a high risk of transmitting HIV (sexual contact with any person, an altercation involving exposure to body fluids, the use of intravenous drugs, tattooing, and any other activity medically known to transmit HIV). • If a correctional officer, employee, or any other person lawfully within the correctional facility believes he or she has been exposed to HIV by an inmate [FLA. ADMIN. CODE ANN. r. 33-401.501 (2008)].

12. Fact • In 1990 in Rhode Island over 40% of all newly diagnosed HIV-infected persons were first tested in a correctional setting. Provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update.

13. HIV CARE IN THE FLORIDA DEPARTMENT OF CORRECTIONS (DOC)

14. Florida DOC has two models of care to manage HIV–infected inmates : • All HIV–infected inmates have access to chronic disease care through the chronic illness clinic-immunity clinic. • Department of Health (DOH) Sexually Transmitted Infection Specialty Clinic at participating institutions Drug formulary: DOC has approved most antiretrovirals and medications used for prevention and management of opportunistic infections. Etravirine, maraviroc and enfurvitide are the only non-formulary antiretrovirals

15. Health Services Bulletin 15.03.05:Immunity Clinic • All HIV-infected inmates are followed by DOC physician or mid-level practitioner • Inmates are seen in clinic as soon as they arrive in the prisons if they are known HIV (+) or as soon as all the baseline tests are done for those newly diagnosed. • Inmate must be followed in clinic at least every 4 months • These appointments are scheduled according to the frequency of follow-up determined by the provider • Laboratory tests are done two weeks prior to the visits. • GOAL: HIV viral load undetectable, prevention of opportunistic infection, and avoidance of medication adverse effects.

16. DOH Sexually Transmitted Infection (STI) Specialty Care Clinic

17. How it Started • DOC needed to improve the HIV and STI care provided to their inmates. • DOC wanted to improve the continuity of care after release. • DOH and DOC agreed to provide STI and HIV specialty care in eight prisons in the DOC.

18. Why are we doing this? What is the benefit to DOC? DOH? DOC • Bring specialty care for STI and HIV-infected inmates • Improve the relationship with another state agency • Better pricing for the STI and HIV drugs • Receive annual certified STI and HIV training by experienced clinicians DOH • Provide specialty care to inmates who will likely return to the County Health Department (CHD) after release • Initiate and maintain a medical record and collect data on potential clients • Improve quality of care during incarceration and maintain it post-release

19. Pilot Project • Duration: two years • CHD: Alachua CHD and Jackson CHD • Alachua CHD: • Hamilton Correctional Institution (CI) • Columbia CI • Union CI • Lowell CI • New River CI • Jackson CHD: • Apalachee CI • Jackson CI • Northwest Florida Reception Center • Implementation date: December 1st, 2008 at Alachua CHD

20. STI Specialty Services • DOC staff will screen all inmates who are: • Male <27 y/o • Females <26 y/o • Pregnant inmates • DOH will record the test results on Health Management System (HMS) or Patient Record and Information Systems Management (PRISM) • DOH medical staff will provide evaluation and treatment when clinically indicated. • Monoinfections with viral hepatitis C are not included in this project.

21. HIV/AIDS Services • DOH staff manage every HIV-infected inmate at the participating institutions. • DOH provides the medications to treat HIV and any HIV-associated  comorbidity. • DOC staff provides the primary care to all the HIV-infected inmates, including emergent, urgent, and afterhours care. • DOC pays for all diagnostic tests and non-HIV specialty care necessary to treat every inmate. DOH staff follows the Utilization Management procedures established by DOC for specialty care.

22. DOH STI Specialty Clinic: Today • Eighteen prisons participate in program • DOC saves approximately $6,000,000.00/year with 340B drug price. • Increased number of patients in virologic control (HIV VL<50). • Model to DOC in other states.

23. Two State Agencies Collaborate • Cost savings and provide specialty care • Reduce transmission of HIV among inmates and post-release by maintaining virologic suppression • Enhance transition from incarceration to the community after release

24. + =

25. Administration of Antiretrovirals • All antiretrovirals are administered under Directly Observed Therapy (DOT) • Inmates go to the medication window (pill line) to receive every dose • The nurse records every dose administered in the Medication Administration Record (MAR) • The MAR is filed in the medical record at the end of each month for review by the clinician during a visit

26. HIV Medication is Highly Effective When Taken as Directed • 100% of people in the Department of Corrections (n=42) who took all pills on time every day had an undetectable viral load by 32 weeks and out to 88 weeks 100 80 Patients Reaching Undetectable HIV RNA LOQ 400 (%) 60 40 DOT <400 SAT <400 20 0 0 4 8 16 32 48 64 72 80 88 Week Directly Observed Therapy (DOT)vs Self-administered Therapy (SAT) Fischl. 8th CROI; 2001; Chicago. Abstract 528

27. HEALTH SERVICES BULLETIN (HSB) 15.03.29 PRERELEASE PLANNING FOR CONTINUITY OF HEALTH CARE EFFECTIVE DATE: August 3, 2009

28. HSB 15.03.29 The purpose of this health services bulletin is to provide guidance to health services staff and classification staff regarding inmate pre-release planning for those inmates who will need continuity of healthcare when released from departmental custody. Pre-release planning shall be completed on all inmates, including temporary releases for special purposes (i.e., furloughs, Immigration and Customs Enforcement [ICE]/detainers) and end-of-sentence releases. Health Service Bulletin 15.03.29 pages 1-4

29. Procedure • Classification staff will provide the medical unit with a weekly list of all inmates who are to be released within the next six (6) months. Medical pre-release health planning will begin at this point. Health Service Bulletin 15.03.29 pages 1-4

30. HIV Pre-release Planning If the inmate designates a provider and chooses to release information, the following data shall be attached to “HIV/AIDS Health Information Summary,” DC4-682. 1. HIV test result showing a Western Blot confirmation of a positive result. 2. Latest CD4 count. 3. Latest viral load test result (if done). 4. Documentation of opportunistic infections and AIDS defining illnesses (lab reports, chest x-ray [CXR] results, and/or notes). 5. Latest tuberculin skin test (TST) test date and results. 6. Date of pneumococcal and influenza vaccine. 7. Antiretroviral history and current treatment. Note: Pre-release packet will be completed by HIV pre-release planner.

31. Take Home • On the day of release, the inmate receives: • Folder with copies of medical record per HSB 15.03.29 • 30 day supply of all medications

32. Re-Entry

33. Reincarceration and HIV • Retrospective cohort study to determine the 3-year reincarceration rate of all HIV-infected inmates (n = 1917) released from the Texas prison system between January 2004 and March 2006. • Analyzed post-release changes in HIV clinical status in the subgroup of inmates who were subsequently reincarcerated and had either CD4 lymphocyte counts (n = 119) or plasma HIV RNA levels (n = 122) recorded in their electronic medical record at both release and reincarceration. Baillergon J. et al. Predictors of reincarceration and disease progression among released HIV-infected inmates. AIDS Patient Care STDS. 2010 Jun;24(6):389-94

34. Results • Only 20%of all HIV-infected inmates were reincarcerated within 3 years of release. • Female inmates and inmates taking antiretroviral therapy at the time of release were at decreased risk of reincarceration. • African Americans, inmates with a major psychiatric disorder, and inmates released on parole were at increased risk of reincarceration. • Mean decrease in CD4 cell count of 79.4 lymphocytes per microliter and a mean increase in viral load of 1.5 log(10) copies per milliliter in the period between release and reincarceration. • Conclusion: highlight the importance of developing discharge planning programs to improve linkage to community-based HIV care and reduce recidivism among released HIV-infected inmates. Baillergon J. et al. Predictors of reincarceration and disease progression among released HIV-infected inmates. AIDS Patient Care STDS. 2010 Jun;24(6):389-94

35. Effectiveness of Antiretroviral Therapy Among HIV-Infected Prisoners: Reincarceration and the Lack of Sustained Benefit After Release to the Community. Retrospective cohort study of longitudinally linked demographic, pharmacy, and laboratory data from the Connecticut prison system to examine the human immunodeficiency virus type 1 (HIV-1) RNA level (VL) and CD4 lymphocyte response to highly active antiretroviral therapy (HAART) during incarceration and upon reentry to the correctional system Conclusion: recidivism to prison was high and was associated with a poor outcome. More effective community-release programs are needed for incarcerated patients with HIV disease. Springer SA et al.Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. 2004 Jun 15;38(12):1754-60. Epub 2004 May 26.

36. Conclusion • Correctional care is a very complex system designed to provide constitutionally mandated care, treatment, rehabilitation, and prevention to incarcerated individuals • Through collaboration with the Florida Dept of Health, the Dept of Corrections has improved the quality and cost-effective care to HIV-infected prisoners • We have recognized a link between correctional healthcare and public health which allow us to release healthier people to be a benefit to our society. • Two main studies showed that we have work to do to improve the linkage to care post-release.

38. THANK YOU