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HIV and Incarceration: Racial Disparities in Overlapping Epidemics

HIV and Incarceration: Racial Disparities in Overlapping Epidemics. August 29, 2013 William Cunningham, MD, MPH UCLA Schools of Medicine/Public Health Departments of Medicine/Health Services. Presentation Outline. Overview of corrections health issues

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HIV and Incarceration: Racial Disparities in Overlapping Epidemics

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  1. HIV and Incarceration: Racial Disparities in Overlapping Epidemics August 29, 2013 William Cunningham, MD, MPH UCLA Schools of Medicine/Public Health Departments of Medicine/Health Services

  2. Presentation Outline • Overview of corrections health issues • Significance of incarceration for public health • Mass incarceration in the US • Health and Health Care for the incarcerated • HIV in incarcerated vs. general populations • LINK LA: intervention to improve linkage to care for HIV+ men released from LACJ

  3. Why should we care? Inmate Health = Public Health • Characteristics of people with history of incarceration: • 25% of HIV-infected Americans • 33% of Americans infected with Hep C • 40% of Americans with active TB • Among inmates • Up to 50% have Axis 1 or 2 mental disorders • 75% alcohol or other substance abuse disorders • Opportunity to impact communities

  4. “It has now become clear that any national strategy for controlling infectious diseases require developing and including prison policies.” WHO Health in Prisons Project

  5. US Correctional System • > 2.3 million in federal or state prisons or local jails • > 10 million booked into 3365 jails annually • > 6 million in Probation System Department of Justice, Bureau of Justice Statistics Available at: http://www.ojp.usdoj.gov/bjs/.

  6. Incarceration rates massively increased since “war on drugs”Number of U.S. Prisoners ( In Thousands )

  7. U.S. Incarceration Rate by Race America’s male prisoners per 100,000 population. By race and ethnicity. 2006. Adult male inmates in prisons and jails. 4.8% of black men. 1.9% of Hispanic men. 0.7% of white men Percentages of black and white men exclude Hispanic men Source: U.S. Bureau of Justice Statistics Bulletin NCJ 217675 – Prison & Jail Inmates. Midyear 2006.

  8. Incarcerated Americans 1910-2006 Sources: Justice Policy Institute Report: The Punishing Decade & U.S. Bureau of Justice Statistics Bulletin NCJ 219416 – Prisoners in 2006.

  9. Jail vs. Prison • Jail is locally operated correctional facility intended for temporary holding • During adjudication • Parole violators • Transfers to other correctional authorities • Sentenced to one year or less • Prison is operated by state or federal govt • Sentence one year or more of incarceration • Usually felony convictions

  10. Large Jails Hold Preponderance of All Jail Inmates • 25 of the largest jails hold 27 % of all Jail Inmates (3365 Jails in U.S.) • Los Angeles County & New York account for 7% of the Nation’s total( 39,695 )* * Data From USDOJ/Bureau of Justice Statistics

  11. Demographics • 3145 per 100,000 black males in prison • 1244 per 100,000 Hispanic males in prison • 471 per 100,000 white males in prison

  12. Mass Incarceration: Magnitude • 1970 – 250,000 incarcerated in US • 2009 – 2,500,000 incarcerated in US • Affected > 30 million Americans • Primarily young minority males, who comprise 3% of the US population • Poorest neighborhoods in urban areas • >90% families affected in communities • After release, mortality 3x higher than gen pop* *Bingswanger, NEJM 2007

  13. Mass Incarceration: Magnitude • 1975 – 2011: 7 million drug incarcerations • 14 million Years of life lost • > 350,000 deaths in similar aged population of US soldiers in World War II • 60% re-incarcerated for administrative violations, not new crimes • Parole/probation violations, misdemeanors • Creates “revolving door” of incarceration

  14. Mass Incarceration: Impact • Socially marginalized • Lifelong impact • 70% recidivism • Stigma • Unemployed, poorly employed` • Homeless • Lose voting rights • Disrupted family life • Children: life span, 6-7x incarceration risk

  15. Presentation Outline • Overview of corrections health issues • Significance of incarceration for public health • Mass incarceration in the US • Health and Health Care for the incarcerated • HIV in incarcerated vs. general populations • LINK LA: intervention to improve linkage to care for HIV+ men released from LACJ

  16. Common Overlapping Health Conditions • Mental illness • Substance abuse • HIV (SAMH 10x more common) • Hepatitis C • Tuberculosis • Preventable pneumonia (influenza) • MRSA • STDs

  17. General Communicable Disease Risks in Jail • Overcrowding • Suboptimal environment, and personal hygiene • Infrequent showers • High mobility and turnover of inmates • Mental health problems 3 – 4X higher among inmates than in the general population • Approximately 75% meet criteria for definition of substance abuse James DJ. Et al. Bur Justice Stat Bull. Sept 2006 Available at: http://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf

  18. STD Risk Factors among Incarcerated • Unprotected sex with multiple partners • Lower education and SES • Personal/Family history of drug abuse • History of physical/sexual abuse • Young age • Racial/ethnic minority status • Only 5 jails in US distribute condoms

  19. Common Sexually Transmitted Infections • Chlamydia - bacterial • Gonorrhea - bacterial • Syphilis - bacterial • Herpes - viral • Trichomonas - parasitic • Bacterial Vaginosis - bacterial • Human Papilloma Virus • HIV

  20. HIV Virus

  21. Presentation Outline • Overview of corrections health issues • Significance of incarceration for public health • Mass incarceration in the US • Health and Health Care for the incarcerated • HIV in incarcerated vs. general populations • LINK LA: intervention to improve linkage to care for HIV+ men released from LACJ

  22. US HIV Data: Burden of Disease, Jail vs. GP • Over 1 million HIV cases in US • 56,000 new infections annually X 20 yrs • Over 18,000 deaths annually in US • HIV prevalence among jail population >5 times higher than that of the GP • ~2% of inmates known to be HIV+ • VS. 0.3% in GP

  23. US AIDS Mortality Data: State Prisoners vs GP • State prisons • Percentage of AIDS deaths: (15-54 yrs) ~ 2x • Inmates: 8.0% • GP: 4.4% • AIDS mortality among inmates (per 100,000) • Male: 12 • Female: 8 • Black: 19 • White: 8 • Hispanic: 4 • > 45 years of age: 23 • 25 – 44 years of age: 5 Maruschak LM. Bur Justice Stat Bull. November, 2006

  24. HIV Testing in LACJ • 500 inmates tested per month • Inmates assessed by MD/RNP if answers yes to “16 questions” • 95% HIV tests ordered in the Inmate Reception Center

  25. Welcome to the Los Angeles County Jail Sheriff Leroy D. Baca

  26. K6G Unit • 100% MSM or MSM/W • 25% IDU • All tested for STDs

  27. HIV Testing Process • Phlebotomist order for HIV test • Blood sample sent to Quest Labs • ELISA and Western Blot • Results: five – seven days later • HIV+ inmate counseled by PHN • Referred to MD and case manager • PHN or Jail HIV Services Coordinator • ~ 20% released prior to case manager referral

  28. “This is great, its not what you think about when you’re on the street!” Simulation using models

  29. HIV: Lack of Continuity of Care after Release • Former inmates with HIV may play important role in maintaining HIV epidemic • Virologic (VL) and immunologic (CD4) outcomes worsen after release • Discharge follow-up and access to care important to limit disease progression and transmission among at-risk communities • Basic needs: housing, transportation, substance abuse and mentalhealth Stephenson BL, et al. Public Health Rep. 2005; 120:84-88 Stephenson BL, et al. Int J STD AIDS. 2006; 17: 103-108

  30. Challenges • Medical care for inmates is often episodic • Insufficient attention given to interventions that would benefit the community upon release • Released inmates impact the community: • Costs of medical care • Crime and recidivism • HIV, other disease transmission • Anti-microbial resistance

  31. Seek, Test and Treat Model: Treat and Retain • Greatest need LACJ: Linkage to HIV care upon release • 57% of HIV+ inmates no care 1 year out • >75% qualify for ART, (CD4 <500 / DHHS) • Well established HIV testing in LACJ • Little chance of STT model success without addressing linkage and retention upon re-entry to community

  32. Presentation Outline • Overview of corrections health issues • Significance of incarceration for public health • Mass incarceration in the US • Health and Health Care for the incarcerated • HIV in incarcerated vs. general populations • LINK LA: intervention to improve linkage to care for HIV+ men released from LACJ

  33. Project LINK LA Effectiveness of Peer Navigation to Link Released HIV+ Jail Inmates to HIV Care William Cunningham, MD, MPH Professor UCLA Schools of Medicine/Public Health Departments of Medicine/Health Services

  34. Los Angeles County Jails Twin Towers • Largest jail system in the world • Daily inmate population: 18,750 - 19,000 (89% male) • Daily inmate processing volume: 750 - 1,000 (Annually = 185,000) • System includes 7 jail sites • Inmates receiving HIV medication per day: ~500 • Approx 4800 HIV+ inmates a year through system / 10% PLHA in LAC

  35. HIV Prevalence:CA Prisons and LAC Jails California Prisons • HIV prevalence among males: 1.4% • HIV prevalence among females: 1.7% Los Angeles County Jails • HIV prevalence among males: 2.7% • HIV prevalence among females: 1.5% Harawa, et al. 2009 J Correctional Health Care

  36. HRSA Continuum of Engagement Not in Care Fully engaged Cheever. Clin Infect Dis 2007;44:1500-1502

  37. LINK LA Addresses the Spectrum of Engagement in HIV Care for Jailed Inmates Re-entering the Community Suppressed Viral Load High risk MSM Linkage to care Engaged in care Re-engaged care Retained in HIV care Adherence to ART medications LINK LA Intervention Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. (2011). "The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection." Clin Infect Dis 52(6): 793-800.

  38. Collaboration: Corrections, Public Health, Academics UCLA Intervention Development; Measurement; Evaluation; Cost Analysis STT MODEL Corrections Setting DHSP Service delivery: - HIV Testing in Jails - Transitional CM - Peer Navigators - Ryan White Clinics SHERIFFS DEPARTMENT (LASD) LA County Jails HIV Care & Treatment in Jails

  39. Primary Research Aims • Two-group experimental RCT design: • The peer-based health system navigation intervention condition for HIV+ inmates upon release from jail • Compared to a usual care condition (transitional case management) • Evaluate the intervention’s effectiveness at improving linkage with and retention in HIV care, self-reported ART adherence, and HIV RNA viral load suppression

  40. Study Design • Phase 1 (Complete): • Key informant interviews to inform adaptation of PN intervention for released inmates • 20 current LACJ inmates; 10 case managers; 11 providers (n=41) • Phase 2 (in progress): • RCT of PN intervention vs. usual Care (176 participants in each arm) • Randomization and baseline assessment in jail • PN intervention delivered over 6 months post release; follow up evaluation for 12 months total

  41. RCT Phase : Recruitment and Randomization • Eligibility: HIV+, 18 years+, post-release LAC residence • In-jail recruitment via DHSP HIV coordinator, transitional case managers, clinical providers • In-jail randomization to intervention or control group (TCM) after baseline interview

  42. Phase 2: Peer Navigator (PN) Intervention • Grounded in Social Cognitive Theory, successful for hard to reach HIV+ persons in LA • Peer Navigators: Paid HIV+ African American and Latino men & women, experience with incarcerated knowledgeable on HIV care • PN trained in MI • Series of sessions delivered in person: • accompaniment with transportation to medical, substance use, mental health appointments, increasing knowledge, linkage and retention skills building, goal setting, support

  43. Phase 2 - Logic Model Behavioral Determinants Activities Immediate -- Outcomes -- Intermediate

  44. Main Intervention Components • Accompaniment • Linkage and Retention Skills Making HIV care appointments - Initial appointment - Follow-up appointments Getting the most out of HIV care and ancillary care appointments • Managing time • Calendar keeping • Patient-managed reminder system Following doctor’s care recommendations

  45. Accompaniment Successful HIV Care Retention HIVeducation Treatment adherence education Linkage & retention skills

  46. Additional Intervention Components • Role model stories • Basic HIV education • Treatment adherence education • Coping with stigma and discrimination • Addressing basic needs • Substance use and mental health screenings and referrals

  47. Main Study Outcomes • Linkage to HIV care post-release • Time to first HIV care visit • Visit within 1st month • Retention in HIV care post-release • Minimum 3 visits/12 mo for those on ART • Minimum 2 visits/12 mo for those not on ART • ART Adherence (self-report, med record) • HIV Viral Load • Specimen collection month 0, 6, 12, and medical record abstraction for additional VL values

  48. Main Study Outcomes cont’d • Costs • Direct cost of running the intervention • Healthcare and jail costs that may be affected by the intervention: HIV care, ER visits, hospitalizations, jail recidivism

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