Linkages to the

HIV Care Continuum among Women in the Criminal Justice System

Anne Spaulding, MD, MPH Rollins School of Public Health

Emory University

Issues 1. Frequency of Incarceration

among Women Living with HIV 2. Health Issues—Continuity of

HIV Care, HCV Treatment 3. Need for Research

Healthcare in Incarcerated Populations • Legal Opinion Deliberate indifference to health needs seen as “cruel and unusual punishment”, a violation of the 8th amendment to the US constitution. Estelle v. Gamble, 1976

• Implications Prisoners guaranteed healthcare. Incarceration offers health benefits some Americans lack. However, priority to address health issues depends on length

of stay.

Women’s Health in Incarcerated Populations • Higher prevalence of infectious diseases than incarcerated men: ◦ HIV (2010: prevalence in men 1.4%, in women 1.9% and unchanged since 2001)* ◦ Syphilis, Gonorrhea, Chlamydia, Viral Hepatitis

• 70 – 80% Alcohol Use/Drug dependency

• High rates of exposure to Violence/Intimate Partner Abuse o 44 – 60% report history of physical/sexual assault

•Specific needs relative to sexual and reproductive health ◦ High rates of menstrual difficulties; Pregnancy upon intake ◦ Need for cervical screening, evaluation for breast disorders, gynecological problems ◦ 2/3 have children under 18

Source: Bureau of Justice Statistics, HIV in Prisons, 2001-2010

HIV in Incarcerated Populations • 12% detainees are women,

• # increasing 5-fold since 1985. 1, 2

•US HIV prevalence in incarcerated persons • ~ 1 – 2 incarcerated persons per 100 has HIV • 1.4% among men; 1.9% among women • National average = 0.36%

• 1 in 6 persons living with HIV in either a jail/ prison at least part of year. 3

• Going through jail predicts virological failure for patients on HAART. 4

Sources: 1. Brennan, 2012. 2. Minton, 2011 3. Spaulding, PLoS One 2009. 4. Westergaard CID 2011.

Atlanta, GA Association between

1. HIV Prevalence 2. Poverty 3. Prison Release Incidence

HIV prevalence is 3 times higher in census tracts with high rates of prisoner release than

neighboring tracts

Source: Centers for Disease Control and Prevention. “HIV prevalence estimates--United States, 2006.” MMWR. 57(39);1073-1076. October 3, 2008; Frew P et al. “Spacial Clustering of HIV Prevalence in Atlanta, GA and Population Characteristics associate with Case Concentrations.” 17th Conference on Retroviruses and Opportunistic Infections (CROI) San Franciso, CA, February 16-19, 2010.; Rich MJ, et al. “Prisoner Reentry in Atlanta: Understanding the Challenges of Transition from Prison to Community.” Emory University, Office of University-Community Partnerships. Available: http://www.oucp.emory.edu/pages/oucp/about.htm. Retrieved: 14 June 2010. 2008.

Finding Cases – Jail Screening • CDC Recommendations on HIV testing: Opt-out screening for patients in all health care facilities, including

correctional settings.1

Annual screening for high-risk persons Screening for all persons with TB and STIs The rate of HIV among prisoners was more than 3.8 times higher than in

the U.S. population at the end of 2006.2,3

• Correctional facilities, however, rarely have sufficient resources to adopt the universal screening approach advocated by the CDC.

Sources: 1. Branson, BM Revised Recommendations for HIV Testing. MMWR. 55(RR14):1-17. 9/22/06. 2. BJS - HIV in Prisons, 2006. 3. CDC- October 3, 2008 MMWR, HIV Prevalence Estimates.

Benefits of Screening Societal: Decrease in transmission

Financial: Saving in medical costs ◦ Each prevented seroconversion = $250,000-$300,000

Potential Source Annual Probability of New Cases

HIV status unknown 0.11

HIV status known 0.02-0.04

On HAART (with undetectable viral load), practice safe sex Nearly 0

Nurse-led Screening in Atlanta, Ga

Total tests given = 58,756

New positives

= 297

Previous positives = 1,959

Total tests offered = 104,136

Test acceptance rate = 56.4%

New cases = 0.5%

Jail as an Unfortunate Medical Home – Results from SUCCESS* Study

Release Time 1 Year

• 50% of individuals recidivated within 1 year.

• 50% of observed laboratory draws occurred upon a return to jail.

*Sustained, Unbroken Connection to Care, Entry Services, and Retention

Results from SUCCESS* Study

• HIV care perimeter very wide after release.

• Jails and prisons are an important point of care for HIV+ individuals passing through the criminal justice system.

Linking to Care after Jail – Results from Atlanta, GA

Greater linkage to care when a discharge planner is involved “SUCCESS”: Sustained, Unbroken Connections to Care, Entry Services, and Suppression

NIDA: R34

Summary 1. Frequency of Incarceration

among Women Living with HIV 2. Health Issues—Continuity of

HIV Care, HCV Treatment 3. Need for Research QUESTIONS?