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HIV CARE IN CORRECTIONS

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Albany Medical College. New York/Virgin Islands. AIDS Education and Training Center ... Albany Times Union, 11/12/00. NY/VI AETC. Epidemiology - HIV in Prisons ... – PowerPoint PPT presentation

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Title: HIV CARE IN CORRECTIONS


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
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
Prison Facilities
  • Federal Prisons
  • State Departments of Corrections
  • NYC Department of Corrections
  • City/County Jails
  • Juvenile Detention Centers

4
Percent of General Population Inmate Population
with AIDS
Percent
Bureau of Justice Statistics, 1998
5
Percent of Inmates Known to be HIV in 1998
10.7
6.3
Percent
3.4
2.3
2.2
1.0
Bureau of Justice Statistics, 1998
6
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
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
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
Percent of State Prison Inmates Known to be HIV
in 1998, by Sex
Percent
Bureau of Justice Statistics, 1998
10
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
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12
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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
HIV Continuity of Care
  • Telemedicine available for follow-up visits via
    PictureTel
  • Phone follow-up facsimile
  • Require dictated discharge summaries for
    hospital discharges

15
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
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17
HIV Education
  • Clinical consultations
  • most use is between 8-500
  • 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 QA

18
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
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
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
Inmate Adherence Video Series
  • Staying the Course Staying on Antiretroviral
    Therapy Once You have Started
  • Taking Charge

22
Inmate Adherence Video Series
  • Collaborative Effort
  • New York State DOCS
  • Private pharmaceutical industry
  • Albany Medical Colleges Div. of HIV Medicine

23
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
Video Projects in Development
  • HIV in Women
  • Spanish Video Series
  • with support from NYSDOH AIDS Institute
  • prevention,getting tested, early intervention
  • treatment, adherence

25
Barriers to HIV Care - 3 Ps
  • Prison level
  • Provider level
  • Patient level

26
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
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
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
Patient Level
  • HIV stigma
  • Reluctance to test for fear of labeling
  • Mistrust of system/authority/medical
  • Language/cultural barriers
  • Confidentiality concerns

30
Patient Level
  • Prior negative experience with health care
  • Attitude
  • Ill take care of it when I get out
  • Addictions
  • Fears
  • antiretrovirals
  • experimentation

31
Opportunities if HIV Status Unknown
  • HIV education
  • Risk factors transmission
  • Offer testing
  • HIV prevention
  • Names reporting partner notification

32
Opportunities if HIV-Infected
  • Education about HIV
  • Explanation of immune system T-cells
  • Explanation of viral load
  • HIV as chronic illness model

33
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
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
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 cant change
  • Few holdouts, but may take months

36
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
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
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
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
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
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
Community Provider Needs
  • Patience
  • Awareness of urgent needs of patient
  • medications
  • intercurrent illness
  • case management
  • Medical records summary
  • Interpreter, if necessary

43
Most Effective Tools
  • Good communication with inmate of plans
  • Assessment of inmates understanding of plan
  • Strong link with CBO identified contact person
  • Peer advocates, both in prison and out

44
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
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
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