Transcript Methadone Maintenance for Prisoners

A Randomized Controlled Trial of HIV
Testing and Linkage to Care at
Community Corrections
Baltimore, MD Investigators
Michael S. Gordon, D.P.A, PI
Timothy W. Kinlock, Ph.D., Co-I
Providence, RI Investigators
Josiah Rich, M.D., PI
Michele McKenzie, M.P.H, Co-I
.
Funded by the National Institute on Drug Abuse (NIDA) Grant# 1R01 DA030771-01
Prevalence of Health Screening
& Services in Adult CJS
% Facilities Providing Service
100
80
60
40
20
0
HIV/AIDS Testing
Prisons
TB Screening
Jails
Hep C Screening
HIV Tx,
Counseling
Community Corrections
Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA
Seek, Test, & Treat: Addressing HIV
in the Criminal Justice System
```
Vietnam
State Receiving Funding
NIDA funded PI
single award
NIDA + NIAID funded PI
NIMH funded PI
Jail/Prison Location
Puerto Rico
What is STTR?
• Goal: Reduce HIV transmission at the
population level
• Aggressively seek hard to reach at risk groups
• Provide HIV testing
• Immediate initiation of treatment with
antiretrovirals
• Retain individuals in treatment over time
RESEARCH SITES
 Baltimore, Maryland (FRI)
 Department of Public Safety and Correctional Services
(DPSCS), Department of Community Supervision (DCS)
 Chase Brexton Health Services (Community Health
Center)
 Providence, Rhode Island (Lifespan/Brown Univ.)
 Department of Corrections Office of Adult Probation and
Parole
 Community Access - a satellite clinic of the Immunology
Center at The Miriam Hospital
STUDY DESIGN
HIV Testing Study (#1)
 Randomized Controlled Trial (RCT)
Condition 1: On site testing (PP office)
Condition 2: Testing off-site (CHC office)
 Male and Female Probationers/Parolees
STUDY DESIGN
Intervention Study (#2)

Randomized Controlled Trial
 Project Bridge-12months
 TAU
 “Rescue” option to crossover after 6-months
 Receive 12-months of Project Bridge


240 HIV positive participants
3,6,12,15, 18-month research follow-up
Project Bridge
 Provide intensive case management, medical,
and social support to HIV infected individuals
after their release from prison.
 Team-based approached.
 Team consists of masters level social worker (MSW)
and outreach worker (ORW).
 Engages client in the community--is based on
collaboration between doctors and social
workers.
Study Procedures
 Research Assistants (RAs) were
stationed in the PP offices
 RA met with potentially-interested
individuals (Screening)
 After signing the informed consentcompleted a baseline assessment (60
minutes)
Study Procedures
 Willing to be tested?
 Randomly assigned to one of two
treatment conditions:
–On-site-tested immediately [Oraquick,
oral swab]; provided with results
–Off-site-given a appointment card to
go to CHC to get tested; provided
results
Study Procedures
Study #2
 Testing positive [rapid]
 Self-identity HIV positive
• Not in treatment
• In treatment, not taking medication
 Consent, baseline, randomize
–PB-set up appointment immediately
–TAU-given passive referral
HIV TESTING STUDY (#1)
SPECIFIC AIMS
 Aim 1: To determine the willingness of the
community corrections population to undergo
HIV testing (Seek).
 Aim 1a: To compare a strategy of rapid HIV
testing on site in community corrections
(probation and parole offices) to referral to an
off site community HIV testing location (Test).
HIV TESTING
PRIMARY OUTCOMES
 undergoing HIV testing (yes vs. no)
 receipt of HIV results (yes vs. no)
INTERVENTION STUDY (#2)
SPECIFIC AIMS
 Aim 2: To determine whether people
with HIV (both known and newly
diagnosed) can be identified in
community corrections.
 Aim 2a: To determine the impact of PB
vs. TAU on individuals with HIV
recruited through CCs.
INTERVENTION STUDY
PRIMARY OUTCOMES
 Time to next (or first) appointment
 Retention
 Initiation of HAART medications
 Proportion of individuals achieving undetectable
HIV plasma
 Viral load over 12 mo. for those prescribed HAART
Seek, Test, & Treat (STT)
Study #1 (Seek, Test)
N
%
Screened
1263
Declined to participate
566
44.8
Randomized
697
55.2
On-Site (PP)
349
50.1
Off-Site (CHC)
348
49.9
Reason for refusing HIV Testing (n=566)
n (%)
Was tested within the past year negative results
170 (30.0)
Was tested within the past month negative results
131 (23.1)
Does not have the time to get HIV tested
81 (14.3)
Only has one sexual partner
51 (9.0)
Does not use/share needles
28 (4.9)
Did not want to be tested
27 (4.7)
Not having unprotected sex
18 (3.2)
Abstaining from sex
17 (3.0)
Rather be tested at doctor’s office
11 (1.9)
Incarcerated past few years
3 (.5)
Other reasons not specified
29 (5.1)
Baseline Site Differences
Examined differences with respect to
baseline characteristics in three ways:
1. Testing site [on-site vs. off-site]
2. Baltimore vs. Providence/Pawtucket
3. Testing site vs. not randomized [refused]
On-Site
(n = 349)
Off-Site
(n = 348)
p
Age, M (SD)
39.0 (11.6)
38.3 (11.1)
ns
Gender, n (%)
Male
Female
284 (81.4)
65 (18.6)
283 (81.3)
65 (18.7)
ns
Race, n (%)
Caucasian
African American
Other
86 (24.7)
184 (52.7)
79 (22.6)
88 (25.4)
193 (55.6)
66 (19.0)
ns
Homeless, n (%)
53 (15.2)
50 (14.4)
ns
CJ Supervision, n (%)
Probation
Parole
Both
289 (82.8)
47 (13.5)
13 (3.7)
270 (77.6)
64 (18.4)
14 (4.0)
ns
BASELINE CHARACTERISTICS
BASELINE CHARACTERISTICS
On-Site
(n = 349)
Off-Site
(n = 348)
p
Crime Days Past 90, M (SD)
4.3 (17.1)
4.0 (16.1)
ns
Incarcerated Days Past 90, M(SD)
12.5 (26.4)
17.1 (29.2)
< .05
Lifetime Incarcerations, M(SD)
11.8 (56.2)
13.7 (71.3)
ns
Drug Use Days Past 90, M(SD)
21.1 (34.0)
14.1 (28.6)
< .01
Heroin Use Lifetime, n (%)
166 (47.6)
136 (39.1)
< .05
IV Drug Use Lifetime, n (%)
90 (25.8)
66 (19.0)
< .05
Previously Tested for HIV, n (%)
325 (93.1)
330 (94.8)
ns
Previously Tested for HCV, n (%)
230 (65.9)
239 (68.7)
ns
Previously Tested for HBV, n (%)
166 (47.6)
176 (50.6)
ns
Baltimore Differences
Variable
%
M
p
Race (AA)
87 vs. 21
<.01
Age (older)
41 vs. 37
<.01
Heroin use lifetime
57 vs. 12
<.01
IDU
26 vs. 18
<.05
Incarceration past 90 days
21 vs. 8
<.01
Crime days past 90 days
6 vs. 2
<.01
On parole
25 vs. 4
<.01
Health insurance
63 vs. 48
<.01
Homeless
19 vs. 10
<.01
Providence/Pawtucket Differences
Variable
%
M
p
Race (Hispanic)
24 vs. 2
<.01
Drug use past 90 days
20 vs. 15
<.01
Legitimate employment
21 vs. 11
<.05
Note: randomized (on-site/off-site) vs. not randomized,
only difference, those randomized were more likely to be on
parole (16.0% vs. 11%; p =.035)
Statistical Analysis
Logistic regression analysis
• outcome measures:
– a) undergoing HIV testing (yes vs. no)
– b) receipt of HIV testing results (yes vs. no)
• explanatory variables in the model:
– a) testing site (on-site vs. off-site)
– b) city (Baltimore v. Providence/Pawtucket).
Undergoing HIV Testing
On-Site (PP)
100%
n=165/174 (94.8%)
Off-Site (CHC)
n=153/175 (87.4%)
80%
60%
40%
n=32/176 (18.2%)
20%
n=14/172 (8.2%)
0%
Balt.
Prov.
Testing site (on-site): p = .0001; City (Baltimore-off-site): p = .0001
Receipt of HIV Testing Results
On-Site (PP)
100%
n=32/32
n=154/165
Off-Site (CHC)
n=150/153
n=14/14
80%
60%
40%
20%
0%
Balt.
Testing site: ns; City: ns
Prov.
Statistical Analysis
Logistic regression analysis
•outcome measures:
– a) undergoing HIV testing (yes vs. no)
– b) receipt of HIV testing results (yes vs. no)
•explanatory variables in the model:
– a) testing site (on-site vs. off-site)
– b) city (Baltimore v. Providence/Pawtucket)
• Additional Covariates (based on Post-Hoc)
–
–
–
–
a) prison jail past 90 days
b) drug use past 90 days
c) heroin use (lifetime)
d) IV drug use (lifetime)
Multivariate Analysis
Undergoing HIV Testing
Testing site (on-site): p = .0001; City (Baltimore-off-site): p = .002
Multivariate Analysis
Receipt of HIV Testing
Note: Individuals reporting lifetime heroin use were twice as
likely to not receive their rapid testing results (85% versus 46%]
Treat & Retain (TR)
Study #2 (Baltimore)
N
%
Screened
138
Ineligible
In care
Phone screen (no-show consent)
Consented (refused randomization)
Randomized
88
79
8
1
50
63.8
PROJECT BRIDGE (PB)
24
48.0
Treatment as Usual (TAU)
26
52.0
36.2
Treat & Retain (TR)-3 Month Treatment Status
Study #2 (Baltimore)
N
%
PROJECT BRIDGE (PB)
In care
Intake completed (missing appointments)
Not in care
24
15
4
5
62.5
16.7
20.8
Treatment as Usual (TAU)
In care
Intake completed (missing appointments)
Not in care
23a
10
8b
5c
43.5
34.8
21.7
a3
participants not yet due for 3-month follow-up assessments
b
2 participants crossed-over to PB
C
1 participant crossed-over to PB
Limitations
 Some participants may have undergone
testing off-site and the results not captured.
 More PPs passed through the CC offices in
which we worked than were approached by
staff.
 Overall sample may/may not be
representative of the overall CC population.
Conclusions
 PP are willing to be HIV tested on-site.
 Rapid HIV testing has the advantage of
providing immediate results, is inexpensive,
and convenient.
 Individuals tested within the past year need to
be encouraged to be tested again.
Conclusions
 HIV + PP can be identified and linked to
treatment in the community.
 It may be feasible to extend HIV testing to
drug courts, day reporting centers, and
other community correction venues.
 Opportunity for PP to partner with CHC for
testing.