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. NY/VI AETC 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. NY/VI AETC Prison Facilities Federal Prisons State Departments of Corrections NYC Department of Corrections City/County Jails Juvenile Detention Centers

4. NY/VI AETC Percent of General Population & Inmate Population with AIDS Bureau of Justice Statistics, 1998 Percent

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

6. NY/VI AETC 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. NY/VI AETC 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. NY/VI AETC 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. NY/VI AETC Percent of State Prison Inmates Known to be HIV+ in 1998, by Sex Bureau of Justice Statistics, 1998 Percent

10. NY/VI AETC 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. NY/VI AETC

13. 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

14. NY/VI AETC HIV Continuity of Care Telemedicine available for follow-up visits via PictureTel Phone follow-up; facsimile Require dictated discharge summaries for hospital discharges

15. NY/VI AETC 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

16. NY/VI AETC

17. 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

18. NY/VI AETC 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

19. NY/VI AETC 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

20. NY/VI AETC 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

21. NY/VI AETC Inmate Adherence Video Series Staying the Course: Staying on Antiretroviral Therapy Once You have Started Taking Charge

22. NY/VI AETC Inmate Adherence Video Series Collaborative Effort: –New York State DOCS –Private pharmaceutical industry –Albany Medical College’s Div. of HIV Medicine

23. NY/VI AETC 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

24. NY/VI AETC Video Projects in Development HIV in Women Spanish Video Series –with support from NYSDOH AIDS Institute prevention,getting tested, early intervention treatment, adherence

25. NY/VI AETC Barriers to HIV Care - 3 Ps Prison level Provider level Patient level

26. NY/VI AETC 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

27. NY/VI AETC 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

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

29. NY/VI AETC Patient Level HIV stigma Reluctance to test for fear of labeling Mistrust of system/authority/medical Language/cultural barriers Confidentiality concerns

30. NY/VI AETC Patient Level Prior negative experience with health care Attitude – “I’ll take care of it when I get out” Addictions Fears –antiretrovirals –“experimentation”

31. NY/VI AETC Opportunities if HIV Status Unknown HIV education Risk factors; transmission Offer testing HIV prevention Names reporting; partner notification

32. NY/VI AETC Opportunities if HIV-Infected Education about HIV Explanation of immune system; T-cells Explanation of viral load HIV as chronic illness model

33. NY/VI AETC 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”

34. NY/VI AETC 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

35. NY/VI AETC 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

36. NY/VI AETC 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

37. NY/VI AETC 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

38. NY/VI AETC 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

39. NY/VI AETC 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

40. NY/VI AETC 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

41. NY/VI AETC 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

42. NY/VI AETC Community Provider Needs Patience Awareness of urgent needs of patient –medications –intercurrent illness –case management Medical records; summary Interpreter, if necessary

43. NY/VI AETC 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

44. NY/VI AETC 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

45. NY/VI AETC 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