Mean streets: Out of prison, out of HIV med compliance
Prisoner re-entry needs targeted focus
[Editor's note: A new study finds a large care gap that imperils the public health response to HIV prevention and treatment. When prisoners are released into the community, they often do not seek care or access their HIV medications. In this issue of AIDS Alert, we examine the implications of this problem and how the study reached its conclusions. Also, in the August, 2009, issue of AIDS Alert, we'll have a story about a New York prison re-entry program that serves as a vehicle for HIV prevention, as well as a way to reduce prison recidivism.]
A number of studies have examined HIV testing, counseling, and treatment in U.S. jails and prisons. Still others have looked at the effectiveness of prison HIV prevention programs.
However, one new study has found a glaring hole in HIV care for prisoners, suggesting the need for a major public health response.
Researchers who examined the antiretroviral therapy (ART) experience of every inmate released from prison in one major state from January, 2004, through December, 2007, found that more than two-thirds did not fill their ART prescriptions within two months of their release.1
The cohort of 2,115 inmates had received optimal HIV care and treatment while in prison, and they were released with 10 days of ART medication, says Jacques G. Baillargeon, PhD, an associate professor of epidemiology in the department of preventive medicine and community health at the University of Texas Medical Branch in Galveston, TX.
However, in this four-year period, only 5% of the newly-released inmates in Texas had obtained HIV medication before exhausting their 10-day supply. Also, 17% had accessed medication within 30 days, and 30% had accessed medication within 60 days.1
"We were very surprised by the findings," Baillargeon says. "This is one of the largest correctional institutions in the United States, and it has a large number of HIV-infected inmates among a racially and ethnically-diverse population."
The Texas prison system's experiences probably are mirrored across the United States, which highlights the public health problem inherent in prisoner re-entry to the community, he notes.
"The Texas prison system and other prison systems do a very good job of getting patients on these medications and having them stay adherent while they're incarcerated," Baillargeon says. "Prison acts as an opportunity to screen, treat, and reach people who are outside of the general health population."
Prisoners often are tested for the first time and then are linked immediately to care. So it is essential to get them linked to community care once they are released, he adds.
"Our hope is that as a result of this study there will be some discussion about improving HIV discharge planning in prisons," Baillargeon says.
This is a public health issue, as much as a compassionate issue, he says.
"This is a public health crisis, and it impacts everybody," Baillargeon says. "These inmates are incarcerated for a few years, and then they're out in the community."
If they are infected with HIV and engaging in high-risk behaviors, there is a big public health issue, he adds.
The study's findings compelled state health and HIV/AIDS officials to hold a summit, scheduled for July 10, 2009, in Austin, TX.
Fifty people were invited to attend the one-day meeting. The attendees represent the Texas Department of Criminal Justice, the University of Texas Medical Branch, the Texas Department of State Health Services, and 25 non-profit agencies, says Dwayne R. Haught, MSN, RN, manager of the HIV medication program, which is an AIDS Drug Assistance Program (ADAP) and part of the Texas Department of State Health Services in Austin, TX.
"We planned this quickly because we wanted to do something quickly," Haught says. "This is just the beginning of something we hope will be ongoing."
The initial goal is to find a way to link more inmates to HIV care upon their return to the community, he says.
"We're looking to strengthen those post-incarceration linkages," Haught says. "We feel strongly that the care provided while they're in the department of corrections is excellent."
But the linkage to community care is unclear.
"We're not sure who's doing what," Haught explains. "So at this meeting we'll look to strengthen those outside linkages."
For example, it might be possible for the state to shift state funds to an ART bridge program for newly-released inmates. This way, they could be directed to immediate drugs through ADAP rather than having to wait until their formal ADAP application is approved, he suggests.
"About 99% of the 115 inmates released each month are eligible for ADAP, but they have to meet strict federal requirements, and you have to do due diligence to prove they don't have any other medication payers," Haught says. "If I can move some of the general (ADAP) revenue to another line in our program, then we could get those people on their medications immediately as we sort out our payer of last resort issue."
It is also crucial that released inmates make appointments with HIV medical providers, which is why the summit is necessary, Haught says.
"We tell HIV providers to overbook their clinics and get the inmates in right away," he says. "We may only have one opportunity to get them into the system, and it's a tough system."
A prison re-entry program in New York offers a glimpse into what can be done for newly-released inmates if a community-based organization (CBO) teams with public health agencies and the department of corrections.
The AIDS Council of Northeastern New York in Albany, NY, has a full-time community re-entry specialist who works with newly-released inmates who are at risk for HIV. Besides providing HIV prevention education, the program assists the men and women with finding housing, jobs, and substance use counseling.
"It's considered a prevention readiness intervention," says Nancy Fisher, director of prevention services for the AIDS Council. "We have a grant through the Department of Health AIDS Institute and a cooperative agreement between the [New York] Department of Corrections and Department of Health."
The AIDS Council started the re-entry HIV prevention program about four years ago after receiving a federal grant, says David Howard, community re-entry specialist.
The goal was to work with at-risk inmates to slow down their prison recidivism rate, engage them in work and in their communities, and to prevent HIV infection, he says. "We're ahead of our time in the state of New York," Howard says.
"There are no other programs that do what we do," he says. "Nobody else meets someone from the prison gate and walks them out of the gate and tries to help set them up."
The re-entry program is an HIV prevention program in a much broader context, Fisher notes.
"It combines all of those skills-building and positive things in their lives, which we see as prevention tools," she adds.
The New York re-entry program represents a good model of prison discharge planning, but it is unique, Baillargeon notes.
"The vast majority of prison systems in the United States would probably have results comparable to ours," he says. "This is a big public health issue because we have a large concentration of HIV-infected persons who move through the correctional system in the United States."
Since HIV infection is over-represented in this population, correctional settings represent an opportunity to screen and educate this group, he adds.
"This is an opportunity we don't want to squander," Baillargeon says. "The fact that we are able to identify and treat these people in prison is a good thing, and the next step is to present good discharge planning."
- Baillargeon J, Giordano TP, Rich JD, et al. Accessing antiretroviral therapy following release from prison. JAMA. 2009;301(8):848-857.