Key Issues in HIV Testing in Jails: Rapid Testing, Linkage to Care and Evaluation

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Key Issues in HIV Testing in Jails Rapid
Testing, Linkage to Care and Evaluation
Rollins School of Public Health of Emory
University Anne Spaulding, MD MPH Kevin
Ramos Abt Associates Inc. Sofia Kennedy, MPH
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Session Overview

• HRSAs Initiative on Enhancing Linkages to HIV
  Primary Care in Jail Settings
• Overview of HIV in jails
• Linkage to care for HIV-positive jail inmates
• Program evaluation in jails

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HRSAs Initiative on Enhancing Linkages to HIV
Primary Care in Jail Settings

• In 2007 the Health Resources and Services
  Administration (HRSA) will fund 10 sites to
  implement demonstration projects to
• Identify HIV-infected inmates.
• Link HIV-infected inmates to HIV care and other
  services in jail and in the community.
• Participate in a rigorous multi-site evaluation.

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HRSA Evaluation Support Center

• The Rollins School of Public Health of Emory
  University and Abt Associates Inc. will serve as
  the Evaluation Support Center (ESC) for HRSAs
  new Initiative on Enhancing Linkages to HIV
  Primary Care in Jails.
• ESC was funded in September 2006 (for five
  years).
• Demonstration sites will be awarded up to
  400,000 per year for four years (2007-2011)
• Total funding for this project 18 million over
  four years.

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HIV in Jails
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Population Dynamics in Prisons Versus Jails (2005)
Credit Nicholas Scharff, MD MPH, from whom this
representation was borrowed. Sources See
Harrison and Beck.1,3
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HIV in Corrections

• Rates of HIV among inmates are up to five times
  higher than the total US population.
• HIV testing in jails is often not systematic,
  even for inmates with longer lengths of stay.
• In one state roughly one third of HIV infected
  persons in the state learned of their HIV status
  while passing through jail.
• CDC issued new Recommendations for HIV Testing
  (2006)
• Includes corrections
• Guidelines for implementing in corrections will
  be issued this summer.

Desai AA, Ltaa ET, Spaulding, et al, AIDS
Education and Prevention 2002
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Benefits of HIV Testing and Community Linkages

• Jails provide an opportunity to
• Identify new HIV-infections.
• Treat HIV-infected inmates
• Known and new positives.
• Those already on treatment and treatment naïve.
• Link HIV-infected inmates to HIV care in the
  community.

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Lessons Learned From An Earlier Project

• CDC/HRSA Corrections Demonstration Project
  (1999-2005).
• HIV care is not always the most pressing concern
  for many releasees.
• Since not all jail inmates are released to the
  community, some went to prison, there needs to be
  more collaboration between jails and state prison
  systems.
• Linkage programs need to be culturally competent.

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Rapid HIV Testing in Jails
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OraQuick Advance
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Credit Robin MacGowan, CDC
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OraQuick Advance (continued)
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Credit Robin MacGowan, CDC
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Uni-Gold Recombigen
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Credit Robin MacGowan, CDC
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Linkage to HIV Care in Jail in the Community
After Release
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HIV Testing and Linkage Program Model
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Linking to Care is a Collaborative Effort
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Components for an Effective Linkage Program

• Offer HIV-positive inmates medical care inside
  the jail.
• Uptake may not be high due to short stays or lack
  of interest.
• Establish linkages between HIV-positive inmates
  and community medical providers.
• Plan for post-release care.
• Follow up post-release to make further linkages.
• Follow up post-release to determine whether
  linkages were made and maintained.

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Mechanisms for Successful Linkages

• Make every effort to obtain accurate information
  on release dates
• Conduct face-to-face discharge planning meetings
• Make appointments and specific and general
  appointments for services

• Schedule first appointment right after release
  (for HIV care or case management)
• Meet at gate at release
• Escort inmates to initial appointments (rather
  than simply offering referrals to providers)

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Program Organization

• Intensive case management to link inmates to
  services.
• Range of services
• HIV care
• Substance abuse treatment
• Mental health treatment
• Housing
• Benefits
• HIV prevention

• Relationships and referral mechanisms with
  community providers.
• Duration of post-release services
• Focus on first appointment.
• Longer-term maintenance in care.
• Hand off from jail/transitional providers to
  long-term community providers.

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Who Are Community Linkage Providers?

• Jail Staff
• Community-Based Organizations
• Community Health Agencies
• Other services or agencies

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Program Design

• Program provides services in both the jail and
  community to link inmates to HIV care and other
  services.
• Case Managers split time between jail and
  community.
• Teams of Case Managers are based in the jail and
  in the community.
• Case Managers meet with inmate at least once
  before discharge if possible.
• Case Managers and inmates develop a discharge
  plan that prioritizes needs and links to
  community providers.
• Case Managers continue to work with the releasee
  in the community to follow-up on the discharge
  plan and make new linkages.

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Benefits of Community Linkages

• Opportunity for HIV infected persons to learn
  their HIV status.
• HIV infected individuals may be linked to care
  sooner.
• Potential positive health outcomes for HIV
  infected individuals and the community.
• Reduce HIV transmission in the community.
• HIV risk behavior changes after infection
  diagnosed.
• Cost savings and ease of burden on the health
  care system.

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Barriers to Community Linkages

• Barriers to coordinated care exist at multiple
  levels
• Client-level
• Anticipation of rejection by service agencies
  based on prior difficulty in trying to negotiate
  system requirements.
• Desire to deny the reality of own at-risk
  behaviors or need for medical/mental health
  intervention.
• Distrust of providers or of certain services
  (e.g., some subcultures are biased against
  accepting mental health services).
• Poor decision making and often irresponsible
  choices.
• Societys perceptions about ex-offenders
• Institutional/service system-level
• Staff-level

Holmes et al. Rossman et al. 1999
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Administrative Issues for Linkage Programs

• Having appropriate space in the jail for the
  program.
• Coordinating the new program with existing
  services.
• Authorizing community-based organizations, public
  health departments and other outside
  organizations to work in the facility.
• Meeting facility security requirements

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Program Sustainability Depends on Evaluating
Jail Health Programs

• To assure funders that money is well spent.
• The inmates and releasees are being served.
• The volume of services delivered.
• Quality assurance on services delivered.
• To determine the best (most efficient, best
  results, cost effective) way to
• Design programs
• Deliver services
• Serve inmates/releasees

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Program Evaluation
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Evaluating Linkage to Care Programs

• Aggregate and individual-level data elements for
  measuring success of linkage programs.
• Data sources
• Evaluation instruments
• Aggregate instruments ( of clients served in
  period)
• Individual-level instruments (characteristics and
  service utilization)
• Utilization of services (provided by program and
  partners)
• Face-to-face interviews with inmates
• Jail administrative and health services databases
  and records
• Community agency databases and records

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In-Jail Data Elements

• approached for linkage program.
• accept linkage program.
• agree to be in the client-level evaluation
• actually served by linkage program

• Document existing community linkages.
• Document any discharge planning services received

Demographics
Need objective measure of need for linkage to
mental health and substance abuse treatment
services.
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Post-Release Data Elements

• Released to street
• Reincarcerated

• Followed-up on discharge plan/new appointments
  (one time)
• Maintained connection to services
• HIV care
• mental health care
• substance abuse treatment
• housing,
• benefits
• HIV prevention

Follow-up interview on post-release service
utilization.

• Attended appointment with program post-release.
• Connected to additional services post-release.

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Conclusion

• Linkage programs vary.
• Programs should be tailored to the jail and its
  inmates.
• HIV services are not always top priority for HIV
  infected inmates.
• Characteristics of inmates will drive scope of
  services.
• Gaining corporation is critical.
• Promotion benefits for staff and inmates.
• Partnership familiarity with corrections.
• Funding adequate funds for testing, linkages and
  evaluation (including locating participants in
  the community).

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Discussion

• What are the issues in implementing linkage
  programs for HIV-positive jail inmates?
• What is the best way to access jail health and
  administrative data?
• What are barriers to collecting/sharing jail
  health and administrative data?

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Resources

• HRSA
• https//grants.hrsa.gov/webExternal/SFO.asp?ID083
  9346E-9F9B-4797-8DA4-13093BCBBF32
• Tools for Grantees
• http//hab.hrsa.gov/tools/spnsgrantees.htm
• CDC Public Health and Criminal Justice
• http//www.cdc.gov/nchstp/od/cccwg/default.htm
• CHIPS Center for the health of incarcerated
  persons
• http//www.chip.sph.emory.edu/JailESC/

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