Transcript NOTE TO SPEAKER - Ohio AIDS Coalition

Transitioning HIV Care From
Corrections to the Community
An Opportunity to Address a Public Health Challenge
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Development of the “Transition” Program
• HIV infection remains a significant public health problem
– Among the general population and incarcerated persons
• The corrections environment presents an opportunity to identify,
manage, and maintain the health of individuals and the
community
• HIV-infected inmates face unique challenges to maintaining their
health
– Challenges may include gender, the type of facility they are
incarcerated in, and how they are transitioned to care after release
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Epidemiology
HIV in the General and
Corrections Populations
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Program Goals
• This program will:
– Present epidemiologic data for HIV in the general
population and in the in-custody population
3
HIV Disproportionately Affects Certain
Populations
Estimated Rate of New HIV Infections by Sex and Race/Ethnicity, 2009
103.9
Male
39.9
15.9
Black
Hispanic/Latino
White
39.7
Female
11.8
2.6
0
50
100
150
Rate per 100,000
Adapted from Centers for Disease Control and Prevention. HIV in the United States: an overview. March 2012. www.cdc.gov/hiv/topics/surveillance
/resources/factsheets/us_overview.htm. Accessed March 28, 2012.
4
Diagnoses of HIV Infection Among Adults and Adolescents
by Transmission Category, 2010 – 46 States and 5
US-Dependent Areas
Transmission Category
Male-to-male sexual contact
New Infections,
No. (%)
29,194 (60.7)
Injection drug use (IDU)
4,007 (8.3)
Male-to-male sexual contact and IDU
1,474 (3.1)
Heterosexual contacta
Otherb
Total
13,357 (27.8)
47 (0.1)
48,079 (100)
Note. All data have been statistically adjusted to account for reporting delays and missing
risk-factor information, but not for incomplete reporting.
a Heterosexual
contact with a person known to have, or to be at high risk for, HIV infection. b Includes
hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Adapted from Centers for Disease Control and Prevention. Epidemiology of HIV infection through 2010. www.cdc.gov/hiv/topics/surveillance/resources
/slides/general/index.htm. Accessed March 28, 2012.
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HIV Incidence in the United States, 2010
Diagnoses of HIV Infection Among Adults and Adolescents, by Sex and
Transmission Category, 2010—46 States and 5 US-dependent Areas
Females, %
(N=10,168)
Males, %
(N=37,910)
12
7
4
1
14
86
77
Male-to-male sexual contact
<1
Injection drug use (IDU)
Heterosexual contacta
Male-to-male sexual contact and IDU
Otherb
Note. All data have been statistically adjusted to account for reporting delays and missing
risk-factor information, but not for incomplete reporting.
a Heterosexual
contact with a person known to have, or to be at high risk for, HIV infection. b Includes
hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Adapted from Centers for Disease Control and Prevention. HIV Surveillance Report, 2010. March 2012. Vol 22. www.cdc.gov/hiv/topics
/surveillance/resources/reports/. Accessed March 23, 2012.
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Persons Subject to Correctional
Oversight, 2010
Number of Individuals
(Millions)
Estimated Number of People in United States Supervised by Adult
Correctional Systems, by Correctional Status
8
7
6
5
4
3
2
1
0
7.08
4.06
1.5
2
Number of individuals released into
0.84 the community annually
0.75 :
Total Population*
Probation
Parole
Jails
→
8,600,000
Community supervision
Prison‡
Local Jails§
Incarcerated†
Note: Estimates rounded to the nearest 100. Data may not be comparable to previously published BJS reports because of
updates and changes in reference dates. Community supervision, probation, parole, and prison custody counts are for December
31 within the reporting year; jail population counts are for June 30. The 2007 and 2008 totals include population counts estimated
by BJS because some states were unable to provide data. See Methodology. *Estimates were adjusted to account for some
offenders with multiple correctional statuses. Details may not sum to total. See Methodology.
†Includes jail inmates and prisoners held in privately operated facilities.
‡Includes prisoners held in the custody of state or federal correctional facilities or privately operated facilities under state or
federal authority. The custody prison population is not comparable to the jurisdiction prison population. See the text box on page 2
for a discussion about the differences between the two prison populations.
§Estimates were revised to include all inmates confined in local jails, including inmates under the age of 18 years who were tried
or awaiting trial as an adult and the number held as juveniles. Totals for 2000 and 2006 through 2010 are estimates based on the
Annual Survey of Jails. See appendix table 4 for standard errors. Total for 2005 is a complete enumeration based on the 2005
Census of Jail Inmates. See Methodology.
Prisons → 597,000
1. Glaze LE. Correctional Populations in the United States, 2010. Washington, DC: Bureau of Justice Statistics; December 15, 2011. 2. Springer SA,
et al. CID. 2011;53:469-479.
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HIV in the Corrections System
• The prevalence of HIV in the corrections system is approximately
4 times that in the general population1
• High-risk behavior is common (eg, illicit drug injection,
unprotected sexual activity)1
Total number of HIV-infected inmates
• Incarceration may be associated with an increased risk for
or inmates with confirmed AIDS
infections such as HIV for high-risk groups such as IVDU
held in state or federal prisons
and MSM1
at year’s end in 2008:
21,987 (1.5% total population)2
IVDU, intravenous drug users; MSM, men who have sex with men.
1. Gough E, et al. BMC Public Health. 2010;10:777. 2. Maruschak LM, et al. Bureau of Justice Statistics Bulletin: HIV in Prisons, 2007-08. January 28, 2010.
bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf. Accessed February 27, 2012.
9
Discussion Question
Given the prevalence of HIV in
correctional settings,
how do you think HIV-prevention
and HIV-management programs
for inmates might affect
public health?
10
Conclusion
Summary
• The incidence of new HIV infection has remained relatively stable
in the general population
• African Americans/blacks, both men and women, have a
significantly higher incidence of new HIV infections compared to
other ethnic/racial groups (2009)
• There are gender-based differences in how men (male-to-male
sexual contact) and women (heterosexual contact) become
infected
– Women are twice as likely to be infected by IDU compared to men
• High-risk behavior is common in the corrections system
• HIV is approximately 4 times more prevalent in the corrections
system compared to the general population
• More than 9 million inmates are released from custody annually
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References
• Centers for Disease Control and Prevention. Epidemiology of HIV infection through 2010. www.cdc.gov/hiv/topics/surveillance
/resources/slides/general/index.htm. Accessed March 28, 2012.
• Centers for Disease Control and Prevention. HIV in the United States: an overview. March 2012. www.cdc.gov/hiv/topics
/surveillance/resources/factsheets/us_overview.htm. Accessed March 28, 2012.
• Centers for Disease Control and Prevention. HIV Surveillance Report, 2010. March 2012. Vol 22. www.cdc.gov/hiv/topics/
surveillance/resources/reports/. Accessed March 23, 2012.
• Glaze LE. Correctional Populations in the United States, 2010. Washington, DC: Bureau of Justice Statistics; December 15,
2011. Correctional Populations in the United States. NCJ 236319. http://bjs.ojp.usdoj.gov/content/pub/pdf/cpus10.pdf.
Accessed March 13, 2012.
• Gough E, Kempf MC, Graham L, et al. HIV and hepatitis B and C incidence rates in US correctional populations and high risk
groups: a systematic review and meta-analysis. BMC Public Health. 2010;10:777.
• Maruschak LM, Beavers RB. Bureau of Justice Statistics Bulletin: HIV in Prisons, 2007-08. January 28, 2010.
bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf. Accessed February 27, 2012.
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The Importance of
Transitioning Care: Inmates
and the Community
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Program Goals
• This program will:
– Illustrate the importance of transitional care
programs, obstacles faced by newly released
inmates, and possible strategies to assist them
2
Discussion Question
What are the challenges faced in
developing successful transition
programs for in-custody patients?
3
The Transition to the Community
Is an Especially Vulnerable Time
• Many received an HIV-positive diagnosis while incarcerated
– 75% initiate ART while in custody, but many discontinue therapy once
released
• ≥90% of newly released inmates do not fill ART prescriptions in
time to avoid treatment interruption
– >80% do not fill their prescriptions within 30 days of release
Baillargeon J, et al. JAMA. 2009;301:848-857.
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The Hierarchy of Needs for the HIV-infected
Former Inmate
HIV
Risk behavior
modification
Mental illness
management
Drug dependence management
Case management:
Shelter, food, employment, and safety
Springer SA, et al. CID. 2011;53:469-479.
Reproduced with permission of Oxford University Press in the format Journal via Copyright Clearance Center.
5
HIV-positive Individuals Returning
to the Community Face Many Obstacles
HIV-positive South Florida Inmates
Require Assistance on Release1
Released Inmates, %
80
70
60
– Welfare Reform Act
• Prohibited from receiving food
stamps or federal assistance
45
50
– Anti-Drug Abuse Act of 1988
• May be denied public housing if
convicted of a crime
67
60
• Additional obstacles2
40
30
30
20
– Reinstating Medicaid
coverage may be delayed
(average of 3 months)
• Benefits affected by duration of
incarceration
10
0
Housing
Case
Management
Obtaining
Substance
Medication Use Treatment
Assistance Required
1. Jordan AO, et al. Policy Brief — Enhancing linkages to HIV primary care and services in jail settings initiative: transitional care coordination — from
incarceration to the community. www.enhancelink.org/sites/hivjailstudy/Policy_brief_Transitional_Care_Coordination_Final_1.27.11.pdf. Accessed March 15,
2012. 2. Wakeman SE, et al. HIV treatment in US prisons. www.medscape.com/viewarticle/725477. Accessed March 1, 2012.
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One Simple Method to Reduce Treatment
Interruptions
• Assist HIV-infected inmates fill out AIDS Drug Assistance
Program (ADAP) forms
– Approximately 5% of inmates who did not receive assistance filling
out forms filled prescriptions within the first 10 days after release
• 18% within the first 30 days
• 26% were still on therapy 60 days postrelease
– Approximately twice as many inmates who had assistance filling out
forms, filled their initial prescriptions
• 34% were still on therapy 60 days postrelease
Whitten L. http://m.drugabuse.gov/news-events/nida-notes/2011/03/hiv-treatment-interruption-pervasive-after-release-texas-prisons. Accessed
February 29, 2012.
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General Strategies to Improve Adherence
to Antiretroviral Therapy (ART)
At Initiation of HIV Management Program
Strategies
Examples
Accessible, trusting, multidisciplinary team
Nurses, social workers, pharmacists, medication
managers
Establish patient’s readiness to initiate ART and form
a trusting relationship with the patient
N/A
Identify potential barriers
Psychosocial issues, active substance abuse or high
risk of relapse, low literacy and/or numeracy, busy
daily schedule and/or travel, lack of disclosure of HIV
diagnosis, skepticism about ART, lack of prescription
drug coverage, lack of continuous access to
medications
Provide patient resources
HIV management referrals, aid in obtaining
prescription drug coverage, pillboxes
Engage the patient in selection of ART
Review regimen potency, side effects, dosing
frequency, pill burden, storage requirements, food
requirements, and the consequences of
nonadherence
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1–Infected Adults and Adolescents.
Washington, DC: US Department of Health & Human Services; March 27, 2012:1-239.
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General Strategies to Improve Adherence
to Antiretroviral Therapy (ART) (cont.)
Ongoing Assessments
Strategies
Examples
Assess adherence at every clinic visit
Simple checklists, multiple team member inquiries
using open-ended questions
Identify types of nonadherence
Not filling prescriptions, not taking the right dose at
the right time, failing to adhere to food requirements
Assess complexity of regimen
Identify reasons for nonadherence
Adverse effects from medications, regimen
complexity (eg, pill burden, dosing frequency),
difficulty swallowing large pills, forgetfulness, failure
to understand instructions, inadequate understanding
of drug resistance and its relationship to adherence,
pill fatigue, other barriers
If resources allow, select from available effective medication adherence interventions:
www.cdc.gov/hiv/topics/research/prs/ma-good-evidence-interventions.htm
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1–Infected Adults and Adolescents.
Washington, DC: US Department of Health & Human Services; March 27, 2012:1-239.
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Discussion Question
How is postrelease adherence
to ART influenced by factors
in your community?
10
Efficient Transitional Care May Be Affected
by Community Factors
• Misperception that the corrections system is not an effective
vehicle for positive changes and set up people to fail
• Medical profession’s concerns about the continuity of care
• Lack of basic needs for former inmates beyond housing,
employment, and transportation
– Personal identification
• Some mental health and substance abuse services require proof of
residence with identification
• Increased cost to the corrections system
Draine J, et al. Policy Brief: strategies to enhance linkages between care for HIV/AIDS in jail and community settings.
www.enhancelink.org/sites/hivjailstudy/Policy_brief_big paper_091310.pdf. Accessed March 15, 2012.
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The Enhancing Linkages Program
• 10 selected organizations developed programs based on local
opportunities and innovations
• Goals of the Enhancing Linkages Program
– Enhanced HIV screening and diagnosis
– Linking HIV-infected individuals to primary care and support services
• Factors that may improve linkages to care
–
–
–
–
Extent of in-jail testing and timely delivery of results
Increased health services in jails
The extent of coordination of outside services
Program involvement to facilitate favorable court treatment
Draine J, et al. Policy Brief: strategies to enhance linkages between care for HIV/AIDS in jail and community settings.
www.enhancelink.org/sites/hivjailstudy/Policy_brief_big paper_091310.pdf. Accessed March 15, 2012.
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Conclusion
Summary
• Many inmates are diagnosed with HIV infection while
incarcerated, but >90% experience treatment interruption upon
release
• HIV-infected inmates, as with other newly released inmates, face
difficulties obtaining everything from healthcare to housing
• Community perception of the corrections system and inmates
may impact efficient transitional care
• Strategies to improve adherence and the delivery of care include
assistance with filling out forms and identifying barriers to care
14
References
• Baillargeon J, Giordano TP, Rich JD, et al. Accessing antiretroviral therapy following release from prison. JAMA.
2009;301:848-857.
• Draine J, Ahuja D, Altice FL, et al. Policy Brief—strategies to enhance linkages between care for HIV/AIDS in jail and
community settings. www.enhancelink.org/sites/hivjailstudy/Policy_brief_big paper_091310.pdf. Accessed March 15, 2012.
• Jordan AO, Ouellet L. Policy Brief — Enhancing linkages to HIV primary care and services in jail settings initiative: transitional
care coordination — from incarceration to the community. www.enhancelink.org/sites/hivjailstudy/Policy_brief_Transitional
_Care_Coordination_Final_1.27.11.pdf. Accessed March 15, 2012.
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents
in HIV-1–Infected Adults and Adolescents. Washington, DC: US Department of Health & Human Services;
March 27, 2012:1-239. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf. Accessed April 11, 2012.
• Springer SA, Spaulding AC, Meyer JP, Altice FL. Public health implications for adequate transitional care
for HIV-infected prisoners: five essential components. CID. 2011;53:469-479.
• Wakeman SE, Rich JD. HIV treatment in US prisons. HIV Ther. 2010;4:505-510.
• Whitten L. NIDA: HIV treatment interruption is pervasive after release from Texas prisons. http://m.drugabuse.gov/news
-events/nida-notes/2011/03/hiv-treatment-interruption-pervasive-after-release-texas-prisons. Accessed February 29, 2012.
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Healthcare Reform,
Medicaid,
and the HIV-infected
Correctional Population
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Program Goals
• This program will:
– Include a discussion of how healthcare reform
may apply to incarcerated individuals
2
Discussion Question
How do you expect healthcare reform
to impact inmate healthcare
pre- and post discharge?
3
The Patient Protection and Affordable Care Act
• Primary purpose of the Patient Protection and Affordable Care Act
(ACA) is to improve access to healthcare1
– Expands Medicaid eligibility to include most people with very low
incomes
Incarcerated
individuals
have significantly
– Prohibits
exclusions
due to pre-existing
conditions
higherlimits
rates
morbidity
from chronic disease
– Imposes
onof
cost-sharing
arrangements
and mental illness than those in the general
• The central tenant of the ACA requires that all Americans have
population
“minimum essential coverage”1
Offenders
generally
2 enter and leave jails in
• Delivery• system
redesign
poor health
– Medicaid Medical Home Option
• 64% of the jail population in the United States turns
– Managing mental illness as chronic disease
over every week
– Emergency psychiatric care
1. Blair P, et al. Increasing access to health insurance coverage for pre-trial detainees and individuals transitioning from correctional facilities under the Patient
Protection and Affordable Care Act. www.cochs.org/files/ABA/aba_final.pdf. Accessed April 6, 2012. 2. National Alliance on Mental Illness. Legislative analysis:
will health care reform help those most at risk? www.nami.org/Template.cfm?Section=CIT&Template=/ContentManagement/ContentDisplay.cfm&ContentID
=110297. Accessed April 16, 2012.
4
ACA-related Coverage Expansions
• Health Benefit Exchanges
– Defined as entities administered by
government agencies or nonprofits
through which qualified individuals
may purchase qualified health plans
(QHPs)
• Alternatively, states may offer basic
health programs that offer standard
health plans (SHPs)
• Incarcerated individuals are
excluded from eligibility for QHPs
and SHPs
– Exception: Inmates awaiting
disposition of charges
• ACA does not specify that
incarcerated individuals cannot
continue to be eligible if enrolled in
a QHP or SHP at the time of
incarceration after conviction
• US Department of Health & Human
Services guidance (2004) regarding
Medicaid:
– Individuals meeting eligibility
requirements may be enrolled
before, during, and after
incarceration
– If this process is completed during
incarceration, individuals may begin
receiving covered services on
release
Blair P, et al. Increasing access to health insurance coverage for pre-trial detainees and individuals transitioning from correctional facilities under the Patient
Protection and Affordable Care Act. www.cochs.org/files/ABA/aba_final.pdf. Accessed April 6, 2012.
5
ACA-related Coverage Expansions (cont.)
• Medicaid expansion
– Beginning in 2014, the ACA will require states to cover most
uninsured individuals younger than 65 years who have an annual
income that is <133% of the federal poverty level
• States have the option to begin phasing in eligibility now
– Consequently, many inmates will likely qualify for Medicaid
• This provision represents the most likely coverage option for offenders
• The Centers for Medicare & Medicaid Services have urged states
to suspend—not terminate—eligibility for incarcerated individuals
Blair P, et al. Increasing access to health insurance coverage for pre-trial detainees and individuals transitioning from correctional facilities under the Patient
Protection and Affordable Care Act. www.cochs.org/files/ABA/aba_final.pdf. Accessed April 6, 2012.
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Challenges Associated With ACA Provisions
• Logistic
–
–
–
–
Few executive-level advocates
Scant data resources
Little continuity of care
Eligibility restrictions on public health programs
• Political
– Internal barriers (eg, attitudes, policies, practices)
– Limited communication of cost-effectiveness data
– Community receptivity
Mellow J, et al. J Urban Health. 2007;84:85-98.
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Opportunities Associated With ACA Provisions
• Expanded access to healthcare coverage
– Correctional authorities may establish linkages with the exchanges
to improve access to Medicaid, QHPs, and SHPs
– ACA requirements for developing enrollment standards and protocols
may provide corrections agencies with a conduit for data exchange
between state and community partners
• Interagency Working Group on Health Care Quality
– Includes the Federal Bureau of Prisons and the US Department
of Health & Human Services
– Established to provide a forum to develop strategies, goals, and
timetables consistent with national ACA priorities
Blair P, et al. Increasing access to health insurance coverage for pre-trial detainees and individuals transitioning from correctional facilities under the Patient
Protection and Affordable Care Act. www.cochs.org/files/ABA/aba_final.pdf. Accessed April 6, 2012.
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Conclusion
Summary
• The purpose of healthcare reform is to improve access to
healthcare, including ensuring that everyone has “minimum
essential coverage” and a redesign of the delivery system
• Inmates generally are in poorer health than the rest of the
population
• Many inmates will meet the new eligibility requirements for
Medicaid
• Inmates may be enrolled before, during, or after their
incarceration and be eligible for Medicaid benefits upon release
• Many challenges remain to providing benefits to newly released
inmates including pending legal challenges to the ACA
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