Transcript HIV Behind Bars

Transitioning Correctional
Patients into the Clinic
Ernesto J. Lamadrid, MD, AAHIVS
Faculty, Florida/Caribbean AETC
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.
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.
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
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.
State or Federal Prison Inmates Reported to be
HIV Positive or to have Confirmed AIDS, 2006-2008
Percent of
custody
population
Total
HIV/AIDS
cases
Year
2006
2007
2008
2006
2007
2008
Reported
21,985
21,644
21,987
1.7
1.5
1.5
Federal
1,570
1,679
1,538
0.9
0.8
0.8
State
20,455
19,965
20,449
1.8
1.6
1.6
U.S. Total
Maruschak, L: HIV in Prisons, 2007-08 December 2009, NCJ 228307
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
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
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. 33401.501 (2008)].
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.
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
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.
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.
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
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
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.
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 HIVinfected 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.
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.
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
+
=
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
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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
Patients Reaching Undetectable
HIV RNA LOQ 400 (%)
HIV Medication is Highly Effective
When Taken as Directed
100
80
60
40
DOT <400
SAT <400
20
0
0
4
8
16
32
48
64
72
80
88
Week
Fischl. 8th CROI; 2001; Chicago. Abstract 528
Directly Observed Therapy (DOT)
vs Self-administered Therapy (SAT)
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
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 prerelease health planning will begin at this
point.
Health Service Bulletin 15.03.29 pages 1-4
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.
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
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
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
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
INCARCERATION
-Mean CD4 Count
increased=74 cells
-Mean HIV viral load
decreased=0.9logs
-59% pts HIV VL<400
27% REINCARCERATIED
-Mean CD4 Count
decreased=80 cells
-Mean HIV viral load
increased=1.14 logs
• 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.
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 costeffective 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.