Welcome! AETC HIV Testing Collaborative

1. Welcome! AETC HIV Testing Collaborative For the audio portion of this meeting: Dial 1-888-205-5513, Enter participant code: 987837# Please turn off your computer speakers

2. Agenda • Welcome • Updates from CDC and HRSA • Benny Farro, Rupali Doshi • Presentations • Jails, HIV Testing, and Linkage to Care Services Anne C. Spaulding, MD, MPH Assistant Professor of Epidemiology and Medicine/Infectious Diseases Emory University, School of Medicine • Immigration and Customs Enforcement (ICE) and HIV Testing Alyssa A. Bittenbender, MPH Program Director Arizona AIDS Education and Training Program Tom Donohoe, MBA Director and Principle Investigator UCLA AIDS Education and Training Center • Next Call

3. Anne Spaulding MD, MPH, FIDSA Assistant Professor of Epidemiology Rollins School of Public Health Emory School of Medicine, Division of Infectious Diseases aspauld@emory.edu Jails, HIV Testing, and Linkage to Care Services: An Overview of the EnhanceLink Initiative

4. Objectives Describe the outcomes of the EnhanceLink Initiative Discuss continued improvement of jail-based HIV testing & linkage of HIV+ releasees to community care

5. Cascade of HIV Care in the U.S. - MMWR 2011 1:6 still unaware of dx Only 1:4 HIV+ suppressed

6. Cascade of HIV Care in the U.S. - MMWR 2011

7. Why is so much of the HIV epidemic seen among incarcerated persons? *Prevalence of HIV is 1.5%, 3-4x that in community • Shared individual risk factors • Injecting drugs—risk for HIV, incarceration • Drug use—disinhibition for sex, criminal behavior • Financing drugs: commercial sex work • Community risk factors • Population level risk—poverty, family breakdown, neighborhood factors • Disproportionate minority confinement.

8. U.S. Correctional Populations: Jails vs. Prisons Prison and Jail Populations at a Single Point in Time: Data from June 2008 Serving Sentences Awaiting trial Approximately twice as many offenders are in prison than jail on any given day Jail N = 0.8 Million Prison N = 1.6 Million Source: Bureau of Justice Statistics (2007-8 data)

9. Rapid Turnover in Jails Number of Individuals Discharged from Prisons and Jailsacross One Year Prison Jail Approximately 95% of the 10 million offenders discharged from the criminal justice system each year are released from jails* Nonetheless, most HIV prevention programs in criminal justice settings have focused on prisons. *Source: Spaulding, PLoS One 2009

10. In the U.S., HIV prevalence =1.5% among prisoners • Only 1-2 out of 100 inmates/releasees has HIV. • BUT, 1:6 persons with HIV in the US is in either a jail or a prison at least part of the year.1 • Going to jail predicts virological failure for patients on HAART.2 HIV CLINIC Source: 1. Spaulding, PLoS One 2009. 2. Westergaard CID 2011.

11. How can we optimize the cascade in jails? Courtesy of Rick Altice

12. EnhanceLink, a Special Project of National Significance (SPNS) funded by HRSA 2006-12 Special Issue on EnhanceLink, October 2013

13. Major Activities: HIV Testing & Continuity of Care Programs LINKAGE TESTING Six Months Post-Release Jail Discharge Enrollment Discharge Planning Intensive Case Management Court Advocacy Housing Basic Needs like Transportation Health, HIV care & Social Service Needs

14. Jail Admission (n=877,119) RESULTS Offered HIV Testing (n=499,131) Tested for HIV (n=210,267) HIV-positive Test Result (n=1,312) Sum of instances when HIV+ persons known to be in jail = 28,649 Newly Diagnosed HIV + (n=822) Previously Known HIV + (n=27,827) Offered Transitional LinkageServices (n=9,837) Enrolled in TransitionalLinkage Services (n=8,056) Enrolled in Client Level Portion ofMulti-Site Evaluation (n=1,386)

15. 6 month data available on 1,270 out of ~ 8000 persons served Client-Level Data:

16. Courtesy of Rick Altice

17. Planning for Success Predicts Virus Suppressed Spaulding, Messina, Kim et al., AIDS and Behavior • 26% of releasees had VL <400 at 6 months post release • Conservative estimate: those for whom data missing were assumed to be UNSUPPRESSED. • Not all persons who were linked were eligible for ART • Factors associated with viral suppression include: • Involvement of case managers in assessing and providing care • These results support further development of case management programs for HIV-positive jail detainees

18. Cost Analysis of Enhancing Linkages to HIV Care Following Jail: A Cost-Effective Intervention(Spaulding et al, AIDS and Behavior) • Mean cost per linked client: $4,219 • Mean cost per 6-month sustained linkage: $4,670 • Mean cost/client achieving viral suppression: $8,432 • Cost per additional quality adjusted life year saved: $72,285 →cost-effective Data suggestEnhanceLink interventions were cost-effective from a societal perspective • But we had to extrapolate from other studies • How many participants would have linked even without EnhanceLink??

19. The Legacy of EnhanceLink— Project IMPact (Funding: FOCUS/Gilead) Continuing Enhancement: HIV Linkage to Care for Jail DetaineesFulton County Jail

20. Model of Integrated HIV Testing • Upstairs (Floors 4-7) • Length of Stay: After 3 days until stay completed • 2nd Floor • Length of Stay: 2-3 days • Right off the street into INTAKE (1st floor) • Length of Stay: 4-24 hours

21. Model of Integrated HIV Testing • Upstairs (Floors 4-7) • 50% • 2nd Floor • 75% • Right off the street into INTAKE (1st floor) • 100%

22. Model of Integrated HIV Testing • Upstairs (Floors 4-7) • 50% • Test at 2nd Floor • 75% • Test at Intake • 100%

23. Upstairs (Floors 4-7) • 50%

24. Fulton County Jail: March 2013 – February 2014 30,316 Eligible Participants Offer rate = XXXX Offer rate = 69.10% 20,947 Rapid HIV Tests Offered Acceptance rate = 81.32% 3,912 Declined Testing, Unable to Consent, or Known Positive Not Tested 17,035 HIV Tests Performed 16,809 Negative 135 Old Positives (diagnosed before) 89 Rapid Tests New Preliminary Positives 422 Declined as Known Positives Positives Identified Through Testing Seropositivity ~ 1.3% 147 Identified Through 2013-2014 Testing Linked to Care 311 Known Positives Linked to Care 458 Linked to Care

25. Case Findings in Jail: Helps the Community Increase in diagnoses Increases Linkage to Care Early ART Adherence to ART Viral Suppression

26. www.HRSA.gov

27. HIV Testing / Linkage trainings for US Immigration and Customs Enforcement (US ICE) clinicians Alyssa Bittenbender, MPH Tom Donohoe, MBA Pacific AETC AETCBorderHealth.org August 11, 2014

28. Educational Objectives • Describe the special needs of the US/Mexico Border region and how the AETCs have collaborated to address them • Review PAETC work with US ICE clinicians over past 4 years, with a focus on HIV testing • Share data from HIV Testing workshops at US ICE facilities, including data demonstrating the importance of in-person events compared with webinars • Share strategies for working with US ICE clinicians and other detention settings

29. There are patients living with HIV in our health jurisdiction (or clinic) who were born in Mexico. • No • Yes 0-5% • Yes 5-10% • Yes 10-20% • Yes more than 20%

30. The Border

31. Regional AETCs

32. The HRSA/Federal definition of the U.S. border region includes communities that are how many miles from Mexico? • Please take a guess even if you have no idea. • 5 miles • 12 miles • 62 miles • 75 miles • 100 miles

33. The Border El Centro, CA San Diego, CA Florence, AZ

34. U.S. Border Region Challenges • Health Professional Shortage Area (HPSA) • Higher incidence of infections diseases compared with the U.S. average • If made a state, the border region would rank: • 1st in number of uninsured children • 2nd in death rates due to hepatitis • 3rd in deaths related to diabetes • Last in access to health care • Last in per capita income Source: US/Mexico Border Health Commission

35. Where the Poor and Uninsured Americans Live

36. HIV Trainings for US ICE Clinicians • Identified needs • Champions are KEY • Routine HIV screening trainings well received • Continuity of HIV care essential • Long term planning and collaboration key to future training and TA plans • Future plans

37. September 2009 “Returned to Risk” Recommendations:“Initiatives to provide cross-border treatment between theUnited States and Mexico could serve as an example in this regard. Programs such as the US-Mexico Border AIDS Steering Team—a hybrid federal and academic program that provides trainings to support HIV-positive detainees returning to Mexico—serve as a model for how treatment can be coordinated for deportees across borders and should be expanded where feasible.”

39. HIV champions pave the way  Congresswoman Lucille Roybal-Allard 40th Congressional District, California LCDR Brent Stephen Health Services Administrator IHSC Medical Clinic Florence Detention Center  Dr. Diana Elson Chief of Public Health, Safety and Preparedness ICE Health Service Corps

40. Training Objectives HIV Testing: Where are we now? • Review CDC HIV Testing Recommendations and the U.S. Preventive Services Task Force Draft Recommendations • Discuss Opt-Out HIV Testing • Underscore the importance of early HIV testing and treatment Assisting HIV-Infected Migrants Who Return to Mexico • Discuss the HIV epidemic along the U.S.-Mexico border • Review evolving health care delivery systems in US and Mexico, including those for HIV services • Facilitate continuity of care for HIV-infected patients returning to Mexico • Utilize 7 one-page bilingual continuity of care fact sheets for Mexico and 6 Central American countries

41. PIF Data

42. Which specific skill and/or information that you learned will you use in your work with HIV/AIDS? • “Use of migrant clinician network for HIV continuity of care.” • “Coordination of care for HIV patients being deported” • “Understanding Mexican healthcare, who to contact to help me.” • “Recommending Seguro Popular.” • “Health care is available to everyone returning to MEX.” How will you apply the information or skill to your work? • “Patient education.” • “Help detainees connect with HIV care in their country.” • “Expanded knowledge to facilitate better patient care.” • “Educating detainees and referrals.” • “Educate staff.” • “I can provide care for deportees.”

43. Resources

46. Links: • BLOG: Training and Technical Assistance for U.S. Immigration and Customs Enforcement (ICE) Clinicians: HIV Champions Pave the Way • FACTSHEET: Information for Health Care Providers with Patients Who Have Been Detained by U.S. Immigration and Customs Enforcement (ICE) • FACTSHEET: Information for Providers Assisting HIV Patients Returning to Mexico and Central America • FACTSHEET: Tips for Implementing Routine HIV Screening on the U.S. – Mexico Border • BROCHURE: New CDC Recommended 4th Generation HIV Testing Algorithm

47. Contact Information Alyssa Bittenbender alyssa1@email.arizona.edu Tom Donohoe tdonohoe@mednet.ucla.edu

49. Next Call • Monday, November 3rd, from 2:00pm-3:30pm ET/ 11:00am-12:30pm PT • Please mark your calendars

50. Thank you!