This presentation was developed for use at the Virginia Department of Corrections Academy for Staff Development. The purpose is to support clinicians and health care providers in correctional settings who provide care to Persons Living with HIV.

1. Special Needs for HIV+
Incarcerated Populations

2. Introductions
• Introduce yourself
– Name
– Facility
– Role in Corrections
– Why you chose this
course
– One thing you hope
to take away from
today

3. Icebreaker

4. WHAT ARE THE DATA SAYING

5. National Incarceration Data
• The 2008 Bureau of Justice Statistics
reported that in 2005 that 1,430,298
persons were incarcerated which was a
9.6% increase from the 2000 Census.1
• Racial and ethnic minorities are
incarcerated at a higher rate than whites in
the United States, and they are
disproportionately infected with HIV.2
1 Census of State and Federal Correctional Facilities, 2005. Bureau of Justice Statistics. October 2008.
2 MMWR; Volume 60, Number 24. Centers for Disease Control and Prevention. June 24, 2011.

6. One out of every …
1 out of every 41 Blacks compared to 1 out of every 245 Whites
1 out of every 21 Black Males compared to 1 out of every 136 White Males
1 out of every 279 Black Females compared to 1 out of every 1064 White Females
1 One in 100: Behind Bars in America. Pew Charitable Trusts – Public Safety Performance Project. February 2008

7. Disparities in Incarceration
• 1 in 30 men between the ages of 20 and 34 is
behind bars, for black males in that age group
the figure is 1 in 9.
• More than 1 in 100 adults is now locked up in
America.
• Men still are roughly 10 times more likely to
be in jail or prison than women.
• For black women in their mid- to late-30s, the
incarceration rate also has hit the 1-in-100
mark.
One in 100: Behind Bars in America. Pew Charitable Trusts – Public Safety Performance Project. February 2008

8. AIDS and Corrections
• A total of 21, 987 inmates held in state or
federal prison on December 31, 2008 were
HIV positive or had confirmed AIDS.
• This accounted for 1.5% of the custody
population.
• 2007 data showed that persons in prisons
for 2.4 times more likely to be
diagnosed with AIDS.
HIV in Prisons 2007-2008, Bureau of Justice Statistics Bulletin. December 2009 (Revised 01-28-10).

9. Virginia Incarceration Data
• According to one expert with the Virginia
ACLU, ―…since 2000, Virginia’s prison
population has increased by 58%.‖1
• In 2009, 4.5% of Medical Monitoring Project
(MMP) interview participants reported that in
the 12 months prior to the interview, they
were put in jail, detention, or prison for longer
than 24 hours.2
• At the end of 2008 there were 433 HIV+
inmates held in the custody of Virginia
Correctional Facilities (State and Federal).2
1 https://acluva.org/7468/take-a-closer-look-virginia%E2%80%99s-recidivism-rate-still-isn%E2%80%99t-great/
2 2011 Virginia Epidemiological Profile, Virginia Department of Health. 2012.

10. Scope of HIV in Virginia 1
• 1 in 380 Virginians is known to be living with
HIV.
• Blacks are 9 times more likely to be living with
HIV than Whites
• For every 5 Virginians living with HIV,
approximately:
4 are Men
3 are Black
2 are Men who have Sex with Men
2 are Ages 20 – 34 at Diagnosis
1 http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/DAta/fact%20sheets/Scope%20of%20HIVAIDS%20in%20VA_2-10.pdf

11. HIV and Corrections in Virginia
• In 2008, Virginia had 433 confirmed HIV
cases in the custody of state or federal prisons
which accounted for 1.3% of the custody
population.
• Of the those inmates, 322 were male and 36
were female.
• In 2007, there were 3 AIDS-related Deaths
leading to a rate of 9 per 100,000 in Virginia
Correctional Settings
HIV in Prisons 2007-2008, Bureau of Justice Statistics Bulletin. December 2009 (Revised 01-28-10).

12. HIV Prevalence in Corrections
• The prevalence of HIV infection in the
United States prison population is more than
three times higher than that of the general
population.1
• While numbers remain high for HIV
prevalence in prisons, the data may
underestimate both HIV prevalence and
incidence due to existing stigma and fear,
which leads to nondisclosure of HIV-positive
status and places prisoners at elevated risk of
infection.2
1Baillargeon,
Jacques, et. al. Predictors of Reincarceration and Disease Progression Among Released HIV-Infected
Inmates. AIDS Patient Care and STDS. Volume 24, Number 6, 2010.
2GMHC. HIV in US Jails and Prisons. http://www.gmhc.org/files/editor/file/a_pa_prison_report0511(1).pdf
Accessed on September 3, 2012.

13. The Testing Gap
By Request, Opt-In, Opt-Out
• A study reported in the 2011 MMWR
showed
– By Request Testing yielded a rate of 1.8 new
HIV diagnoses per year.
– Opt-In Testing yielded a rate of 5.1 new
diagnoses per year.
– Opt-Out Testing yielded a rate of 7.6 new
diagnoses per year.
MMWR;. Volume 60, Number 24. Centers for Disease Control and Prevention. June 24, 2011.

14. Discussion
• What are the data telling us about the
populations affected by HIV and
Incarceration?
• What are the likely opportunities for
Corrections to support the eradication of
HIV-related Morbidity and Mortality?
• What do persons working Corrections
need to know to contribute effectively and
in a meaningful way?

15. HIV RISK AND PREVENTION

16. Where in the Body is HIV Found?1
• HIV lives only in human body fluids. HIV
is found in the greatest amounts in these
body fluids:
– Blood
– Semen
– Fluid from a woman’s vagina and/or cervix
– Breast Milk
– Fluid around parts inside the body – fluid
around the brain, joints, lungs, heart, belly and
amniotic fluid
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

17. HIV Transmission
Behavior RISK
Sharing Injection Equipment MOST RISK
Receptive Anal Sex
Receptive Vaginal Sex
Insertive Anal Sex
Insertive Vaginal Sex
Receptive Oral Sex
LEAST RISK
Insertive Oral Sex

18. How HIV is NOT Spread.1
Through contact with … Fluids that DO NOT transmit HIV
• Doorknobs • Saliva
• Beds • Tears
• Food
• Sweat
• Clothes
• Hugging • Urine
• Coughing • Feces
• Toilet seats
• Mosquitoes
• Telephones
• Water fountains
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

19. The Chain of Infection 1
1. Someone Or Something Must Have The
Virus (Source)
2. The Virus Needs A Way To Leave The
Body (Exit)
3. The Virus Needs A Way To Enter
Another Person's Body
4. HIV Needs Someone Able To Get
Infected (Susceptible Host)
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

20. Methods to Prevent the
Transmission of HIV
• HIV Negative and HIV Positive Individuals
– Abstinence from Sexual Activity
– Use a condom every time you have sex.
– If you inject drugs, don't share your needles or
syringes.
• HIV-Positive Individuals
– Take your anti-HIV medications according to your
health care provider’s directions.
– Don’t share your razor, toothbrush, or other items
that may have your blood on them.
– If you are a mother infected with HIV, don’t
breastfeed your baby.

21. Prevention for Positives
• Prevention with Positives
– Secondary Prevention
• Secondary prevention activities are aimed at early
disease detection, thereby increasing opportunities
for interventions to prevent progression of the
disease and emergence of symptoms
• Example: Rapid HIV-1 Antibody Testing

22. Prevention for Positives
• Prevention with Positives
– Tertiary Prevention
• Tertiary prevention reduces the negative impact of an
already established disease by restoring function
and reducing disease-related complications.
• Example: PCP Prophylaxis

23. Activity
• With your partner role play:
– How you would explain
1. HIV Risk Behaviors
2. HIV Transmission
3. HIV Prevention

24. HIV DISEASE

25. Viral Life Cycle
http://www.haroldsmithlab.com/research_3.htm

26. HIV Disease Progression
VL
CD4

27. Disease Progression
CD4 Cell Count Categories Clinical Categories
Abbreviations: PGL = persistent generalized lymphadenopathy
#
A B* C
Asymptomatic, Acute HIV, or PGL Symptomatic Conditions, not A or C AIDS-Indicator Conditions
(1) ≥500 cells/µL A1 B1 C1
(2) 200-499 cells/µL A2 B2 C2
(3) <200 cells/µL A3 B3 C3
STAGES OF HIV IMAGE, Source: http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-your-body/stages-of-hiv/ Accessed
on 09/03/12
WHO/CDC Clinical Staging Chart Source: http://www.aidsetc.org/aidsetc?page=cg-205_hiv_classification Accessed on 09/03/12

28. Activity
• With your partner take role play
– How you would explain
1. HIV Risk Behaviors/Transmission/Prevention
and
2. HIV Life Cycle
3. HIV Disease Progression

29. HIV TREATMENT

30. Why is this important?
• ―… one study indicated that 75% of HIV-infected
inmates initiated their first antiretroviral treatment
while incarcerated.‖1
• ―Unfortunately for those receiving HIV-related
care, incarceration and/or release can sometimes
disrupt HIV treatment regimens and lead to a loss
of access to vital ancillary services.‖1
• ―Further, delays in HIV treatment and care of new
inmates and treatment interruptions, resulting from
transfers or disciplinary actions, can lead to missed
medications and the possible emergence of drug-
resistant HIV strains, particularly in jail settings.‖1
1Harawa, Nina and Adimora, Adaora. Incarceration, African Americans and HIV: Advancing a Research Agenda. J
Natl Med Assoc. 2008 January; 100(1): 57-62

31. HIV Treatment
• Anti-retroviral Therapy (ART)
– Medication Classes
• Entry Inhibitors (EI)
• Reverse Transcriptase Inhibtors
– Nucleoside/tide Reverse Transcriptase Inhibitors (NRTI)
• Non-Nucleoside Reverse Transcriptase Inhibitors
(NNRTI)
• Integrase Inhibitors (II)
• Protease Inhibitors (PI)
– Multidrug Combination Products (also known as
Single Regimen Treatment - SRT)
http://www.niaid.nih.gov/topics/HIVAIDS/Understanding/Treatment/pages/arvdrugclasses.aspx

32. Medication Targets
http://www.bcm.edu/molvir/hivaids

33. Medications by Type/Class
NRTIs NNRTIs PIs EIs IIs STRs
Combivir* Endurant Aptivus Fuzeon Isentress Atripla*
Emtriva Intelence Crixivan Selzentry Dolutegravir Complera*
Epivir Recriptor Invirase Elvitegravir The Quad**
Epzicom Sustiva Kaletra
Retrovir Viramune Lexiva
Trizivir* Norvir
Truvada* Prezista
Videx Reyataz
Combicistat – booster
Viread Viravept medication for Protease
Inhibitors
Zerit Indicates:
* Combination Pill
Ziagen ** No Brand Name

34. Antiretroviral Side Effects
• Hypersensitivity • Peripheral Neuropathy
• Anemia • Vivid Dreams
• Diarrhea • Anxiety
• Rash • Depression
• Constipation • Weight Loss
• Nausea • Muscle Pain
• Fatigue • Appetite Loss
• Chills • Joint Pain
• Dizziness • Fat Loss in arms, legs, or
• Headaches face
• Insomnia • Numbness
• Pancreatitis

35. Treatment Guidelines 1
• ART is recommended for all HIV-
infected individuals.
• The strength of this recommendation
varies on the basis of pretreatment CD4
cell count:
– CD4 count <350 cells/mm3 (AI)
– CD4 count 350 to 500 cells/mm3 (AII)
– CD4 count >500 cells/mm3 (BIII)
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/guidelines

36. Treatment Guidelines 1
• Regardless of CD4 count, initiation of
ART is strongly recommended for
individuals with the following conditions:
– Pregnancy (AI)
– History of an AIDS-defining illness (AI)
– HIV-associated nephropathy (HIVAN) (AII)
– HIV/hepatitis B virus (HBV) coinfection
(AII)
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/guidelines

37. Treatment Guidelines 1
• Effective ART also has been shown to
prevent transmission of HIV from an
infected individual to a sexual partner.
• Therefore, ART should be offered to
patients who are at risk of transmitting
HIV to sexual partners (AI [heterosexuals]
or AIII [other transmission risk groups]).
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 02/22/13 from: http://aidsinfo.nih.gov/guidelines

38. Treatment Guidelines 1
• Patients starting ART should be willing and
able to commit to treatment and should
understand the possible benefits and risks
of therapy and the importance of
adherence (AIII).
• Patients may choose to postpone therapy,
and providers, on a case-by-case basis, may
elect to defer therapy because of clinical
and/or psychosocial factors.
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 02/22/13 from: http://aidsinfo.nih.gov/guidelines

39. Recommended Regimens for
Treatment Naïve Patients
• Atripla
• Reyataz + Norvir + Truvada
• Prezista + Norvir + Truvada
• Isentress + Truvada
http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/11/what-to-start accessed on 03/05/13

40. Laboratory Monitoring Schedule
Prior to and After Initiation of ART1
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/aa_tables.pdf

41. Laboratory Monitoring Schedule
Prior to and After Initiation of ART1
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 09/03/12 from: http://aidsinfo.nih.gov/guidelines

42. Laboratory Monitoring Schedule
Prior to and After Initiation of ART1
1Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. AIDSinfo; US Department
of Health and Human Services.
Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/aa_tables.pdf

43. The Importance of Adherence 1
• Anything below 95 percent adherence has been
associated with increases in viral load and drug
resistance.
• Therefore adherence to antiretroviral treatment is
extremely important.
This means missing no more than one
dose a month, if taking antiretroviral
drug treatment once a day.
1http://www.avert.org/antiretroviral.htm Accessed on 09/03/12

44. HIV Drug Resistance1
• HIV drug resistance refers to the ability of the
virus to withstand the effects of a given
antiretroviral drug to prevent its replication.
• Drug resistant virus will continue to replicate in the
presence of the drug to which it has become
resistant.
• Insufficient knowledge among patients and health
workers, suboptimal adherence to treatment
regimens, drug stock-outs, and inadequate patient
monitoring mechanisms, are among the many
factors leading to treatment failure and eventually
drug resistance.
1World Health Organization. HIV Drug Resistance Fact Sheet. April 2011

45. HIV Drug Resistance1
• If patients develop HIV drug resistance to
their first-line regimen, they stop responding
to it effectively. In order to stay healthy, they
need to receive a second-line regimen.
• In 2010, in low- and middle-income countries,
second-line treatment regimens were on
average at least six times more expensive than
first-line treatment.
• Keeping drug resistance at bay is therefore a
key strategy to the success and sustainability
of HIV treatment programmes.
1World Health Organization. HIV Drug Resistance Fact Sheet. April 2011

46. Tips for ART Adherence 1
• Learn about the things that keep HIV patients from taking
their meds, and think about how you can deal with them if you
have those issues. Some factors include:
– Untreated depression/mental illness
– Substance abuse
– Complicated medical instructions
– Medication side effects
– Dietary restrictions
– Difficulty reading or understanding directions
– Homelessness or unstable housing
– Stigma
– Travel
– Overall ―fit‖ of the drug regimen/schedule to the patient’s
lifestyle and daily routine
1http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/treatment-adherence/index.html
Accessed on 09/03/12

47. Positively Aware
Annual HIV Drug Guide
• Published Annually
• Reviews ALL
Medications
• Reviews:
– Medication Class
– Manufacturer
– Dosage
– Side Effects/Toxicity
– Drug Interactions
– Doctor Comments
– Community Comments

48. Activity
• With your partner take role play
– How you would explain
1. HIV Risk Behaviors/Transmission/Prevention
2. HIV Life Cycle/Disease Progression
and
3. HIV Treatment
4. HIV Treatment Adherence and Side Effects
5. HIV Drug Resistance

49. OPPORTUNISTIC INFECTIONS

50. Opportunistic Infections
• Opportunistic infections are infections that
occur if you have a weakened immune
system.
• People with weakened immune systems can
even get infections from organisms that
don’t usually cause diseases in health
people.
• People with AIDS die from Opportunistic
Infections, not AIDS or even HIV itself!!!

51. Opportunistic Infections1
• Bacterial diseases
– tuberculosis, MAC, bacterial pneumonia and septicaemia (blood
poisoning)
• Protozoal diseases
– toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis
and leishmaniasis
• Fungal diseases
– PCP, candidiasis, cryptococcosis and penicilliosis
• Viral diseases
– such as those caused by cytomegalovirus, herpes simplex and
herpes zoster virus
• HIV-associated malignancies
– Kaposi's sarcoma, lymphoma and squamous cell carcinoma.
1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
Accessed on 09/03/12

52. Opportunistic Infections
Occurrence by CD4 Count1
• Greater than 500 cells/mm3
– In general, people with CD4 counts greater
than 500 cells/mm3 are not at risk for
opportunistic infections.
– For people with CD4 counts around 500,
however, the daily fluctuations in CD4 cell
levels can leave them vulnerable to minor
infections, such as candidal vaginitis or yeast
infections.
1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
Accessed on 09/03/12

53. Opportunistic Infections
Occurrence by CD4 Count1
• 500 to 200 cells/mm3
– Candidiasis (Thrush)
– Kaposi’s Sarcoma (KS)
• 200 to 100 cells/mm3
– Pnuemocystis Jirovecii Pneumonia (PCP)
– Histoplasmosis and Coccidiodomycosis
– Progressive Multifocal Leukoencephalopathy
(PML)
1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
Accessed on 09/03/12

54. Opportunistic Infections
Occurrence by CD4 Count1
• 100 to 50 cells/mm3
– Toxoplasmosis
– Cryptosporidiosis
– Cryptococcal Infection
• 50-100 cells/mm3
– Cytomegalovirus (CMV)
• Less than 50 cells/mm3
– Mycobaterium Aviam Complex (MAC)
1http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
Accessed on 09/03/12

55. Its really quite atrocious
Supercalifragilisticexpialidocious You have progressive
multifocal
leukoencephalopthy

56. Tips for delivering information
• Understand the issue yourself
• Speaking simply
– Not talking down
• Allow for questions
• Ask patient to repeat back what you have told
them
• Metaphors can be a helpful tool
– Overly complex can be a negative
• Confidential Space

57. Activity
• With your partner take role play
– How you would explain
1. HIV Risk Behaviors/Transmission/Prevention
2. HIV Life Cycle/Disease Progression
3. HIV Treatment/Adherence/Side
Effects/Resistance
and
4. Opportunistic Infections

58. CO-MORBIDITIES

59. Key Morbidities in HIV 1
1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview of
systematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.

60. Research on HIV Co-Morbidities1
• In the United States up to 50% have a
mental illness such as depression, and 13%
have both a mental illness and substance
use issues.
• They are also more likely to be co-infected
with other sexually transmitted infections,
and with hepatitis B and C.
1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview of
systematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.

61. Research on HIV Co-Morbidities1
• People with HIV are twice as likely to experience
depression compared to the general population.
• Coping style and psychological distress are
strongly associated with HIV disease progression,
even more so than stress stimuli.
• Alcohol use is associated with a significant decrease
in HAART adherence, however, studies regarding
other substance use were inconclusive.
• The metabolic effects of combination therapies for
HIV increase the risk for insulin resistance, type 2
diabetes and poor cardiovascular disease outcomes.
1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview of
systematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.

62. Research on HIV Co-Morbidities1
• The four comorbid conditions that have received
the most attention are tuberculosis (TB), Hepatitis
C (HCV), other sexually transmitted infections and
pneumococcal infections.
• HCV increases the risk of mortality for people
with HIV and HIV accelerates HCV disease
progression.
• People with HIV have a statistically greater risk of
acquiring TB than the general population.
• Multi-drug resistant (MDR) TB is an increasing
concern particularly in urban residents, the
homeless, and males.
1Wilson MG, Chambers L, Bacon J, Rueda S, Ragan M, & Rourke SB. Issues of comorbidity in HIV/AIDS: An overview of
systematic reviews. Toronto, ON: Ontario HIV Treatment Network; 7 December 2010.

63. Veteran’s Comorbidity Study
• The sample consisted of 33,420 HIV-
infected veterans and 66,840 HIV-
uninfected veterans.
• Comorbidity was common (prevalence,
60%–63%), and prevalence varied by HIV
status.
1Goulet,
Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING AND
INFECTIOUS DISEASES • CID 2007:45 (15 December)

64. Comorbidity Variance
• For conditions that tended to decrease in
prevalence with age (i.e., substance use disorders,
psychiatric disorders, and liver disease), veterans
with HIV infection experienced a less pronounced
decrease than did HIV-uninfected veterans.
• For conditions that tended to increase in
prevalence with age (i.e., hypertension, diabetes,
vascular disease, pulmonary disease, and renal
disease), veterans with HIV infection experienced a
more pronounced increase than did HIV-
uninfected veterans
1Goulet,
Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING AND
INFECTIOUS DISEASES • CID 2007:45 (15 December)

65. Comorbidity Variance
• Substance use disorders were more
common among HIV-infected veterans
than among HIV-uninfected veterans (27%
vs. 22%; ).
• Psychiatric disorders were more common
among HIV-uninfected veterans than
among HIV-infected veterans (22% vs.
18%; ).
1Goulet,
Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING AND
INFECTIOUS DISEASES • CID 2007:45 (15 December)

66. Comorbidity Variance
• Low CD4 cell count was associated with a
decreased odds of substance use disorders
and psychiatric disorders.
• Detectable viral load was associated with
substance use disorders.
• Detectable viral load was also associated
with a greater risk of having a comorbid
condition and multimorbidity.
1Goulet,
Joseph L., et. al. Do Patterns of Co-Morbidity Vary by HIV Status, Age, and HIV Severity? AGING AND
INFECTIOUS DISEASES • CID 2007:45 (15 December)

67. Immunizations for HIV Positive Adults1
All Some Not Recommended
HIV Positive Adults HIV Positive Adults HIV Positive Adults
• Hepatitis B Virus • Hepatitis A Virus • Anthrax
• Influenza • Hepatitis
A/Hepatitis B • Smallpox
• Polysaccharide Combined Vaccine • Zoster
Pneumococcal • Haemophilus
• Tetanus and Influenza Type B
Diphtheria • Human
Papillomavirus
Toxoid
• Measles, Mumps,
• Tetanus, and Rubella
Diphtheria and • Meningococcal
Pertussis • Varicella
1Recommended Immunizations for HIV Positive Adults. AIDSinfo; US Department of Health and Human Services. Reviewed
June 2009.
Accessed via web 03/05/13 from: http://aidsinfo.nih.gov/contentfiles/Recommended_Immunizations_FS_en.pdf

68. PSYCHO-SOCIAL IMPACT

69. HIV and Psycho-Social Impact
• Stigma and Discrimination
• Misinformation
• Segregation/Separation Practices
• AIDS
• Disclosure

70. Coping with HIV and AIDS 1
• Denial
• Anger
• Sadness or Depression
• Fear and Anxiety
• Stress
1Coping withHIV and AIDS: Mental Health. HIVInSite: http://hivinsite.ucsf.edu/insite?page=pb-daily-mental
Accessed on 09/03/12

71. Identifying Emergent
Mental Health Needs1
• Some changes that might be significant
include:
– Experiencing ―panic attacks‖
– No longer finding enjoyment in activities which
usually make you happy
– Withdrawing from social interaction
– Change in memory functioning
– Sleeping too much—or being unable to sleep
– Feeling ―sad‖ or ―empty‖ much of the time
– Feeling guilty
– Feeling tired all the time
1http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/mental-health/index.html
Accessed on 09/03/12

72. Disclosure Study
• Negative consequences included stigma,
rejection by sexual partners and others, loss
of intimacy, and threats to personal well-
being.
• Positive rewards resulting from disclosure
included increased social support and intimacy
with partners, reaffirmation of one's sense of
self, and the opportunity to share personal
experiences and feelings with sexual partners.
1Parsons JT,
et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS
Education and Prevention. 2004 Oct;16(5):459-75

73. Activity
• In your small group, take ten minutes and
using two sheets of newsprint brainstorm
the following:
– Thinking about disclosure of HIV status to
medical staff:
• What are the barriers to disclosure?
• What are the benefits to disclosure?
• Choose a recorder and a presenter to share
with the large group your brainstorming.

74. CORRECTIONS

75. Guide for HIV/AIDS Clinical Care1
• HIV Care in Correctional Settings
– ―Given the high HIV seroprevalence among
inmates, the reentry of inmates into the
community presents a danger of spreading HIV
and other infectious diseases, and it is a public
health concern.‖
– ―Education should focus on the use of latex
barriers with all sexual activity.‖
– ―… inmates with a history of IDU should be
educated about the risks of sharing needles and
injection equipment, specifically the high risk of
transmitting or acquiring HIV, HCV, and HBV.‖
1Department of
Health and Human Services. Guide for HIV/AIDS Clinical Care. January 2011.
Accessed 09/03/12: http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-00-contributors.html

76. Recommended
Counseling Messages
• These counseling messages should be reinforced for all
inmates diagnosed with HIV infection:
– Do not have sex while in prison; do not have unprotected
sex upon release to the community.
– Do not shoot drugs.
– Do not share tattooing or body piercing equipment.
– Do not share personal items that might have your blood on
them such as toothbrushes, dental appliances, nail clippers
or other nail-grooming equipment, or razors.
– Cover your cuts and skin sores to keep your blood from
contacting other persons, and report to your health care
provider should you have an open, draining wound.
1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.

77. Recommended Guidance to
HIV Infected Inmates
• Additionally, inmates with HIV infection
should be given the following guidance:
– Do not donate blood, body organs or other
tissue, or semen.
– Always wash hands before eating, after
touching contaminated clothing/bedding, after
attending to personal hygiene, after gardening
or other outdoor activities, after touching
animals, or after touching any other
contaminated items.
1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.

78. Recommended Guidance to
HIV Infected Inmates (cont.)
• Additionally, inmates with HIV infection
should be given the following guidance:
– Wash fresh fruits and vegetables thoroughly
before eating.
– Avoid eating undercooked or raw meats.
– Stop smoking, and do not begin smoking
again upon release.
– Avoid touching stray animals.
1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.

79. Staff Guidance for Infection
Control When Managing Inmates
• Staff should use the following infection control
guidelines when managing inmates:
– Use correctional standard precautions when in contact with
any inmate’s blood or other potentially infectious materials,
whether or not the inmate is known to have HIV
infection.
– Use infection control practices in which non-disposable
patient-care items are appropriately cleaned, disinfected, or
sterilized
– Take measures to prevent cross-contamination during
patient care (e.g., dialysis, vascular access, cauterizing, or
dental procedures)
– Use the appropriate airborne, droplet, and/or contact
transmission precautions
1Federal Bureau of Prisons. Management of HIV Care. Clinical Practice Guidelines. June 2011.

80. Correctional Officers 1
 Know how HIV/AIDS is and is not
transmitted.
 Respond to issues that impact an inmate’s
treatment for HIV; your efforts will benefit
your job, your fellow officers and the
community you live in.
 Confidentially refer inmates to health services
and to other programs such as peer education,
substance abuse and/or mental health
programs.
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

81. Correctional Officers 1
Keep open communications with facility
health staff.
Challenge coworkers, friends and family
members regarding myths and beliefs
about HIV/AIDS.
Incorporate standard precautions and
prevention techniques into day-to-day work
to reduce/eliminate the spread of
HIV/AIDS.
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

82. Correctional Facility
―To Do List‖1
• Policy and Procedures
– to safeguard the confidentiality and prohibit
any unauthorized disclosure of confidential HIV
related information, inside or outside the facility
– specifying when there is a “reasonable need”
to get or use confidential HIV related information
(for the purpose of supervising, monitoring,
administering, or investigating the programs and
health or social services the facility coordinates
with)
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

83. Correctional Facility
―To Do List‖1
• Provide safeguards to prevent
discrimination or abuse of inmates who
have been tested for or diagnosed with
HIV/AIDS
• Prevent and deal with occupational
exposure where there is a significant risk of
HIV transmission
• Provide training for staff on confidentiality
and the facility’s ―need to know‖ policy
1HIV/AIDS Training for Correction Officers Working in Local Correctional Facilities – NYSDOH AIDS Institute

84. Opportunities for Clinicians to
Educate Patients1
Medical care providers can affect
HIV transmission by:
1. Screening their HIV-infected
patients for risk behaviors
2. Communicating prevention
messages
3. Discussing sexual and
drug-use behavior;
positively reinforcing
changes to safer behavior
4. Referring patients for
services
MMWR; Recommendations and Reports. July 18, 2003 52(RR12);1-24. CDC. July 18, 2003.

85. Discussion
• What role can corrections play in the fight
against HIV in our communities and in our
facilities?
– Prevention
– Treatment
– Education
– Empowerment?

86. RESOURCES

87. Comprehensive HIV/AIDS
Resources and Linkages for Inmates

88. Resources
• US Department of Health and Human Services
– www.aids.gov
• Centers for Disease Control and Prevention
– www.cdc.gov
• Health Resources and Services Administration
– www.hrsa.gov
• AIDS Info
– www.aidsinfo.nih.gov
• US Department of Justice
– www.usdoj.gov
• Virginia Department of Health
– www.vdh.virginia.gov

89. Final Thought …
America is a nation of second chances and
those leaving prison should have the
opportunity to change.
Governor Bob McDonnell
2011 State of the Commonwealth

90. Closing and Evaluation
• Questions?
• One thing you learned that you didn’t know?
Thank you!