Shaping HIV & Correctional Health Care: Research Questions Moving

Forward

Redonna K. Chandler, Ph.D.Division of Epidemiology, Services, and

Prevention ResearchNational Institute on Drug Abuse

July 22, 2012

U.S. imprisons more people per capita than any other country in the world, with 239% growth in 1990s

53

100

112

116

125

139

400

628

702

91

73

85

0 100 200 300 400 500 600 700 800

Japan

Sweden

France

Germany

Italy

Australia

Canada

Spain

England and Wales

South Africa

Russian Federation

United States

Inmates per 100K CitizensSource: International Centre for Prison Studies, www.prisonstudies.org

U.S. Adult Offender Population: Since 2005, combined federal, state, local adult correctional population

has been over 7 million.

Source: Bureau of Justice Statistics, 2009

Prevalence of Health Screening

& Services in Adult CJ% Facilities Providing Service

Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA

Westergaard RP et al., J Int AIDS Soc 2012; 15:10.

IDU HIV+ Are Much Less Likely to Receive HAART

Percentage Of Providers Who Would Defer ART By CD4+ Count and Injection Drug Use Status

Unanswered Research Questions

• How can HIV services be integrated across the criminal justice system?

• What is the resistance?• What organizational change is

needed?• What workforce is needed?• What implementation strategies

work?• What will it cost and is it cost-

effective?• What interventions are needed to

reduce stigma associated with drug use, HIV, criminal justice involvement?

HAART as HIV Prevention

GD Kirk, et al., 2001, Poster presented at the 18th Conference on Retroviruses and Opportunistic Infections , Boston MA, February 27-March 3, 2011.

Montaner et al., Lancet 2008

In a Given Year . . . About 14% of all people in the US with HIV,

& 33% of those with HCV,

& 40% of those with TB

-- will pass through a correctional facility.

In a Given Year . . . About 14% of all people in the US with HIV,

& 33% of those with HCV,

& 40% of those with TB

-- will pass through a correctional facility. Source: Spaulding et al. (2009); Hammett,

Harmon, & Rhodes (2002).  AJPH, 92 (11), 1789-1794.

Treatment planning for drug abusing offenders should include strategies for chronic medical conditions (e.g. HIV/AIDS, Hep B/C, & TB)

ENTRY(Arrest)

ADJUDICATION(Trial)

PROSECUTION(Court, Pre-Trial Release, Jail)

SENTENCING(Fines, Community Supervision,Incarceration)

CORRECTIONS(Probation, Jail, Prison)

COMMUNITY REENTRY(Probation, Parole, Release)

Crime victimPoliceFBI

Crime victimPoliceFBIJudge

Key Players

Screening/Referral

Intervention Opportunities

ProsecutorDefense AttorneyDefendantJuryJudge

JudgeJury

Probation OfficersCorrectional Personnel

Probation/ Parole OfficersFamilyCommunity-based providers

Diversion ProgramsDrug CourtsCommunity TreatmentTASC

Drug CourtTerms of IncarcerationRelease Conditions

Drug Treatment

Drug treatmentAftercareHousingEmploymentMental HealthHalf-way HouseTASC

N/A

Where and How do you Implement STTR in the Criminal Justice System?

Seek Test Treat Retain

```

State Receiving FundingNIDA funded PI single awardNIDA + NIAID funded PINIMH funded PIJail/Prison Location

Seek, Test, & Treat: Addressing HIVin the Criminal Justice System

Puerto Rico

Vietnam

How do we Implement Effective Interventions?

• What is the cost of STTR? Is it cost-effective?• What assessment tools can communities use

to determine which evidence-based STTR components to implement?

• What are the structural/organizational requirements for different evidence-based STTR interventions?

• What implementation strategies facilitate uptake?

Baillargeon J et al., JAMA 301(8):848-857, 2009.

Percentage of Inmates Who Filled an

ART Prescription Within 60 Days of Release

Perc

ent

5.4%

17.7%

30%

0

20

40

60

80

100

10 days 30 days 60 days

Only a small percentage of Texas prison inmatesreceiving ART while incarcerated filled an initial ART prescription within 60 days of release

Had prescriptionfilled within:

How do we Promote Patient Sustained Adherence to

HAART?

• What is the role of addiction treatment (including medication) in HAART adherence?

• What individual barriers impede HAART adherence?

• What structural and cj system barriers impede HAART adherence?

• What role can technology play in HAART adherence?

How Do We Leverage Our Scientific Investment?

Data Harmonization

Economy, Power, Answer New Questions

Increase cross-study comparability, collaboration, scientific yield• Multi-site pooling for integrative

data analyses• Cross-site

replication/comparisons• Meta analyses• Secondary data analyses

Maximizes gain while minimizing cost, risk, and time to payoff

Promotes construct quantification through integrative data analysis

WHY HARMONIZE?

Central core measures are used in every study, forming a pool of common itemsSpecialty core measures may be asked based on specific interests of a sub-set of studiesExample: Cost/Cost Effectiveness, Climate/Culture of Jails Regarding HIV Intervention, etc.

The Cores

STTRHarmonizat

ion Constructs

Demographics

Mental HealthCJ

Status

Drug Use

HIV/IDU Risk

HIV/HCV

Testing

Access to Care

Treatment Utilization Adhe

renceBiological

DataMeasure Level

Construct Level

VAS, HAART ACTG Questionnaire, ART Pill Count, Chart Review

Item Level

Core Domains

Thank YouQuestions

www.drugabuse.gov/aids