HIV and STD Programs in Jail

Hampden County, Massachusetts

T Lincoln

March 2002

Corrections Statistics- USA

• 2 million incarcerated (world ~ 8 million)• Including probation and parole, 6 million persons

involved with corrections- 3% of all U.S. Adults• 13% of African-American men cannot vote due to

this• “Invisible population”• 25% of some neighborhoods• Incarceration rate has more than tripled since 1980• “34th state”

Percent of Total Burden of Infectious Disease Found Among People Passing Through

Correctional Facilities, 1996Condition Estimated # of

releases w/ Cond’n Total # in US Pop’n

w/ Cond’n Releases as %

of US Pop’n w/ Cond’n

AIDS

39,000 229,000 17%

HIV+ 98,000-145,000 750,000 13-19%

HepBsAg+ 155,000 1-1.25 million 12-16%

Hep C+ 1.3-1.4 million 4.5 million 29-32%

TB disease 12,000 34,000 35%

Hammet T, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999

HIV DATA 2000

• Massachusetts– annual AIDS rate = 18.9 per 100,000– 31% IDU, 27% female

• Metropolitan Springfield (population ½ million)– annual AIDS rate = 24.2 per 100,000– 44% IDU, 37% female

• Hampden County Correctional Center– 5.5% of men and 8.7% of women HIV positive

on intake (1996)– usually ~75 known HIV patients at jail

Community Integrated Correctional Health Care

The Hampden CountyPublic Health Model

Public Health Model- Current Structure

• 4 jail health teams integrated with 4 community (neighborhood) health centers

• Patients assigned to health team by zip code or prior association with community health center

• Dually based team members in 4 health centers and jail

• Physicians and HIV case managers primarily community health center based

• Nurse practitioners, primary nurses primarily jail based

• Community corrections (probation/parole/DRC) component in development

Public Health Model for Corrections

• Education

• Prevention

• Early detection

• Treatment

• Continuity of care

• Reservoir of Illness

• Proactive v. Reactive

• Sentinel function

• Public Health Department

• Community-integrated model

Model for Correctional Health Care: Evaluation

• Support: CDC, Soros Foundation, NIJ

• Various facets: Chronic conditions (medical and mental), prevention (HIV, STD, TB, viral hepatitis), HIV treatment, continuity of care

• Cost: $9-10/inmate-day, 10% of $44 million budget. ACA average cost prisons 10%. MA 12%.

• Economic analysis: A-team– HIV prevention- voluntary counseling & testing– Urine chlamydia screening and partner services

Hampden County Correctional Center

• 1800 inmates- 90% men, 10% women

• Pretrial and sentenced

• % released: 20% 36% 67%at: 3days 2wks 3mo

• 70% street drugs- 80% past month, 11% men & 25% women shared needles

• 46% in jail in past year

HCCC intake population- self-report 2Q1999

• Sexual Behavior: – 49% sex within a year and never use condom, – 70% drink/use drugs during sex– 11% report prior chlamydia

• HIV/AIDS: – 69% ever tested for HIV– 83% feel low/no chance of getting HIV

HCCC program flow• Intake health screen- day 1

– Nurse visit- Brief history & exam includes HIV history, mental health screen

– RPR, CBC, ALT, PPD planted – UA (with leukocyte esterase), pregnancy test,

since 2/99 urine LCx for chlamydia & brief STD questions

– Gonorrhea- Gen-Probe if symptoms, risk, LET+

• Intake Unit- day 1-3/4– Education and orientation- includes HIV/hepatitis.

Video, instructor led, peer education.

HCCC program flow

• History and Physical- day 3/4– Nurse practitioner– Documentation of HIV test acceptance/refusal

• HIV voluntary counseling and testing– Referral from:

• Prior medical (priority fast-tracked) and education events

• Ongoing education programs• Care of other medical concerns• Patient request

HCCC program flow

• HIV voluntary counseling and testing (cont’d)– MA Dept Public Health lab and VCT questionnaire

• STD – Treatment– Partner elicitation and outreach through MA DPH

STD Disease Intervention Specialist includes partners of men with chlamydia

• Continuity of care– HIV: Case management is key. 90% show rate at

follow-up after release

Key Points

• Jail is community. Almost everyone returns. Temporarily displaced. At risk.

• Public health opportunity.• Triad of corrections, community and public

health.• Program description- set the stage• Need for economic analysis to inform resource

allocation