The document discusses a project called EnhanceLink that provided HIV testing and linkage to care services for individuals being released from 20 jails over 6 years, finding that 26% of those enrolled had suppressed viral loads 6 months after release, with involvement of case managers in care being a key factor of success. It also presents results of an evaluation and cost analysis finding the interventions were cost-effective from a societal perspective.

1. HIV and Jails: A Public Health
Opportunity
September 19, 2013

2. Agenda
Introduction to SPNS Integrating HIV
Innovative Practices (IHIP) project
Sarah Cook-Raymond, Impact Marketing +
Communications
Presentations from
 Barry Zack,The Bridging Group
 Dr. Anne Spaulding, Emory University
Q & A

4. IHIP Jail Linkage Resources:
 Lessons Learned Manual
 Implementation Guide
 Webinar Series
 HIV and Jails: A Public Health Opportunity – today’s
Webinar September 19, 2013 (archive recording will be
up shortly)
 How to Build and Expand a Jail Linkage Program –
September 27, 2013 at 12pm ET
 Creating Partnerships and Navigating the “Culture of
Corrections”- October 3, 2013 at 2pm ET
www.careacttarget.org/ihip

5. Other IHIP Resources
 Buprenorphine
 Training Manual, Curricula, and Webinars on
Implementing Buprenorphine into Primary Care Settings
 Engaging Hard-to-Reach Populations
 Training Manual, Curricula, and Webinars on Engaging
Hard-to-Reach Populations
 Oral Health
 Forthcoming:Training Manual, Curricula, and Webinars on
Oral Health and HIV

6. Enhancing Linkages to HIV Primary
Care and Services in Jail
HIV and Jails:
A Public Health Opportunity
Barry Zack September 19th, 2013
The Bridging Group

7. Outline:
• Introduction (brief) to U.S. Correctional System
• Epidemiology of Health / Corrections
• Public Health and Public Safety
• Linkages: Continuity of Care

8. United States Incarceration Rates
• More than 1 in 100 American
adults were incarcerated at the
start of 2008.
• One in every 31 American adults,
or 7.3 million Americans, are in
prison, on parole or probation.
• US has over 25% of all people
incarcerated worldwide.
• Approximately one in every 18
men in the US is behind bars or
being monitored.

9. 9
Jails in the United States
 85% of incarcerated
individuals pass solely
through jails
 Each year this accounts for
nearly 13 million jail
admissions—representing 9
to 10 million unique
individuals—in the United
States.
 This equates to
approximately 4% of the
U.S. adult population
passing through a jail in a
given year.
9

10. 10

11. Criminal Justice System
• Law enforcement
▫ Police, sheriff, highway patrol, FBI, etc.
• Adjudication
▫ Courts
• Corrections
▫ Jails, prisons, probation and parole

12. Types of Correctional Supervision
• Probation
• Jail Custody
• Prison Custody
• Parole

13. Distribution of Population

14. Jail vs. Prison
• Jail
▫ Operated by local law enforcement agency (e.g. County
Sheriff’s Department)
▫ Pre-Trial, Trial, Short Term Sentences (usually up to one
year)
▫ Range of offenses (e.g., misdemeanor & felony)
• Prison
▫ Typically operated by State DOC or Federal BOP
▫ Tried and convicted
▫ Felony offenses
• Private Jails and Prisons: local and state agencies
may also contract these operations to a private entity

15. Why Jails? Over 95% of persons released
from correctional facilities leave jails!
Annual Admissions Average Daily Population

16. Security Levels
• Minimum
▫ Not considered a serious risk to the safety of staff, peers or to
the public
▫ Many facilities have transitional/re-entry programs
• Medium
▫ May present a risk of escape or pose a threat to peers or staff
▫ May have programs buy may be based on individual’s
conforming behavior with institutional rules and regulations
• Maximum
▫ Maximum control and supervision through the use of high
security parameters, internal physical barriers and check
points
▫ Present serious escape risks or pose serious threats to
themselves, peers, or staff
▫ May have limited access to programs

17. Percent of Total Burden of Infectious
Disease passes through Jails/Prisons
• Total HIV/AIDS 15%
• Chronic Hepatitis B 12-16%
• Hepatitis C 29-32%
• TB Disease 38%

18. Health and Incarceration
• STDs - significantly higher
• Mental Illness - 45-64%
▫ 10-17% SMI
• Substance Use – 43-69%
▫ 30% have co-occurring SMI
• Aging related - significantly higher
▫ Hypertension
▫ Diabetes

19. Prevalence of Various Conditions
Compared to General US Population
4.1
5.5
17
11
13
0
2
4
6
8
10
12
14
16
18
HIV AIDS HCV TB Mental
Illness
FoldIncreaseinPrevalence

20. HIV prevalence (%) in selected
countries
0
5
10
15
20
25
30
35
40
45
Canada Brazil USA Honduras Spain RF Vietnam Indonesia Ukraine South
Africa
Adults
Prisoners

21. HIV Prevalence Among Those
Released From Prison/Jail in 2006
Estimate of proportion of HIV+
persons in US who passed
through a jail or prison in 2006
1 of 7 (14.1%) of all HIV+ in US
were released from
incarceration in 2006
At least 22% of all HIV+ black
men in US passed through a
correctional facility during
2006
Incarcerated/released
Not incarcerated
Total US HIV population ~ 1.1 million
Spaulding A, et al. PLoS One. 2010.
85.9
14.1

22. HIV Prevalence in the 12 City Jails:
Metropolitan Statistical
Area
Average
Daily Jail
Population
Estimated HIV Prevalence Rates
Atlanta, Georgia
Baltimore, Maryland
Chicago, Illinois
Dallas, Texas
District of Columbia
Houston, Texas
Los Angeles, California
Miami, Florida
New York City, New York
Philadelphia, Pennsylvania
San Juan, Puerto Rico
San Francisco, California

23. HIV Transmission in Correctional Settings
• Majority of people with HIV are infected before they enter prison1
• HIV risk behaviors often continue inside the institution and include
injecting drug use, tattooing, body piercing, and consensual,
nonconsensual, and survival sexual activities2
• Scarcity of sterile drug paraphernalia leads to syringe sharing in
prison3
• Syringe sharing among soon-to-be released individuals is high4
1. CDC. MMWR. 2006;55(15):421-426. 4. Stephens TT et al. Am J Health Stud. 2005.
2. Hammett TM. Am J Pub Health. 2006;96(6):974-978.
3. Davies R. Lancet. 2004:364:317-318.

24. Cycle of Incarceration
Community Jail
Court
Prison

25. Relationships in the Community

26. When Prison Enters
the Picture

27. Concurrent Relationships
in the Community

28. A Community at Risk
• Reality Check:
▫ It is estimated that each year, approximately 14% of
all HIV positive persons in the US spend time in prison or
jail.
• People come into facilities with higher rates of infectious diseases
• Most people (over 90%) in correctional facilities will return to
the community
• Incarcerated does not occur in a vacuum. People move in and
out of prisons and jails and likewise move in and out of
communities and relationships.
• Correctional medical care and health programs represent access

29. Unique Access
• High turnover of people in prisons and jails
creates a flow of individuals who may have
access to health care only when incarcerated.
• The correctional setting may be the only place
where people get care, treatment and support.

30. The Collaboration:
Culture of Corrections
• Working within/inside a Correctional Setting
• Working with the Correctional System
• Patience & Persistence….

31. Issues to Consider
• Disconnect between Corrections and Public Health
• Different Cultural Identities
• Security= Safety First
• Operational Policies, Procedures and Relationships
• Confidentiality
• Ethical Considerations

32. The Disconnect
Public Health Jail & Prison
 Mission = Public Health
 Orientation toward Change
 Humanitarian
 Dress code is (more) Informal
 Prevention/Screening/Care
 Client/Community-Centered
 Flexibility
 Creative
 Mission = Public Safety
 Orientation toward Order
 Para-Military
 Dress code is Uniform
 Punishment (rehabilitation….)
 Institution-Centered
 Rules
 Standard Operating Procedures

33. Addressing Public Health Supports the
Mission of Public Safety
• Safety and security is the number one priority of
every correctional facility.
• Evidenced based health education, prevention,
screening and continuity of care, post release, can
contribute to the safety and security mission of a
detention setting.
“People, who are actively working to better themselves,
are less likely to get into trouble on the inside. Thus,
more programs make my prison safer.”
- Former Warden, San Quentin State Prison

34. The Linkages Challenge:
What are we doing?
Screening
Diagnosis
– Infectious diseases (HIV, STI, TB, HCV,
HBV)
– Mental illness
– Substance abuse
 Treatment
 Pre-release planning
Making the transition work!
 Linkage to care and services
Treatment
ID (HIV, HCV, STIs, HBV, etc.)
Chronic (hypertension, diabetes)
Substance Use & Mental Health
 Adequate community resources
Addressing life’s competing
priorities
How to break the cycle?
 Societal challenge (poverty, discrimination, etc.)
 Policy (Sentencing, Drugs, Housing, Sex Offenders)
Incarceration Freedom
Reincarceration

35. Project START for People with HIV
• RCT
▫ Individual and Ecosystem
▫ Jail and Prison
• Medication use
• Medication adherence
• Recidivism
• Sexual behavior

36. New & Ongoing Issues to Consider:
• ACA
▫ Major CJ implications: time of enrollment and eligibility to
coverage of mental health and substance use treatment
• Criminogenicity
• Electronic Medical/Health Records
▫ HIPAA, consent
• Multi-lingual / cultural competency
▫ Context of CJ and Medical Care
 Conditions of Probation and Parole
• Patient’s life competing priorities
▫ Income, housing, family, etc.
• Trust & Relationships & Linkages
▫ Medical, Healthcare and CJ systems

37. HIV Linkages to Care
• Linkages to HIV treatment providers in the
community after release
• Seamless medical care
• Additional support services
▫ case managers, benefits counselors
• Access to other treatment providers
▫ substance treatment, mental health, etc.

38. In conclusion:
• Most people in jail will return to the community
• People coming into jail (as a population) are relatively
unhealthy
• The burden of disease is much greater than in the
general population
• Critical to comprehend the context of the criminal
justice system to pro-actively work with systems and
patients

39. In Conclusion:
•The jail setting represents access to a
population to improve community health.

40. Thank you….
For more information:
•www.thebridginggroup.com
•barry@thebridginggroup.com

41. EnhanceLink Initiative to Link HIV+
Jail Releasees to Community Care –
A Legacy of Lessons Learned
Anne Spaulding MD MPH—Emory University, Atlanta Georgia
PI, EnhanceLink Evaluation and Support Center
Funder: HRSA
Dates: September 2006 – August 2012
Number of Sites: 10; Number of Jails Served: 20
Cost: $22 Million

42. Major Activities: HIV Testing & Continuity of
Care Programs
Enrollment Jail Discharge
Six Months
Post-Release
Discharge Planning Intensive Case Management
Court Advocacy
Basic Needs like
Transportation
Health, HIV care
& Social Service
NeedsHousing
TESTING

43. Enhance Link Care Sites and Partners
Evaluation and Support Center: Emory University/Abt Associates

44. Jail Admission
(n=877,119)
Jail Admission
(n=877,119)
Offered HIV Testing
(n=499,131)
Offered HIV Testing
(n=499,131)
Tested for HIV
(n=210,267)
Tested for HIV
(n=210,267)
HIV-positive Test Result
(n=1,312)
HIV-positive Test Result
(n=1,312)
Previously Known
HIV + (n=27,827)
Previously Known
HIV + (n=27,827)
Offered Transitional Linkage
Services (n=9,837)
Offered Transitional Linkage
Services (n=9,837)
Newly Diagnosed
HIV + (n=822)
Newly Diagnosed
HIV + (n=822)
Sum of instances when HIV+
persons known to be in
jail = 28,649
Enrolled in Client Level Portion of
Multi-Site Evaluation (n=1,386)
Enrolled in Client Level Portion of
Multi-Site Evaluation (n=1,386)
Enrolled in Transitional
Linkage Services (n=8,056)
Enrolled in Transitional
Linkage Services (n=8,056)
EnhanceLink Study Population Admission, Testing & Service Events

45. • Ten manuscripts have been submitted
• Special issue will also include:
▫ An overview authored by the Guest Editors
▫ Commentary by AT Wall, Director of the Rhode
Island Department of Corrections
▫ Appendix detailing methods of the EnhanceLink
initiative
AIDS AND BEHAVIOR
SPECIAL ISSUE

46. Planning for Success Predicts Virus Suppressed
Spaulding, Messina, Kim et al., AIDS and Behavior
• 26% of releasees had VL <400 at 6 months post release
– Conservative estimate: those for whom data missing were
assumed to be UNSUPPRESSED.
– Not all persons who were linked were eligible for ART
• Factors associated with viral suppression include:
– Involvement of case managers in assessing and providing care
• These results support further development of case
management programs for HIV-positive jail detainees

47. Cost Analysis of Enhancing Linkages to HIV Care
Following Jail: A Cost-Effective Intervention
(Spaulding et al, AIDS and Behavior)
• Mean cost per linked client: $4,219
• Mean cost per 6-month sustained linkage: $4,670
• Mean cost/client achieving viral suppression: $8,432
• Cost per additional quality adjusted life year saved:
$72,285 →cost-effective
Data suggest EnhanceLink interventions were cost-
effective from a societal perspective
• But we had to extrapolate from other studies
• How many participants would have linked even without
EnhanceLink??

48. Poll
1. What percentage of HIV+ men in a jail population
acquired their infection through having sex with men?
a. 2% b. 6% c. 20% d. 40%
2. Is the presence of a serious mental illness in a jail releasee
associated with a higher or lower likelihood of
linkage/retention in care after release?
3. If 28% of persons in the US with HIV have suppressed
virus, what percentage of persons leaving jail can achieve
viral suppression at 6 months when linkage services are
available?
4. If models of excellence are now established in 20 jails
across the US, how do we transfer information to the
other 3200?
OTHER FINDINGS

49. Poll
1. What percentage of HIV+ men in a jail population
acquired their infection through having sex with men?
a. 2% b. 6% c. 20% d. 40%
2. Is the presence of a serious mental illness in a jail releasee
associated with a higher or lower likelihood of
linkage/retention in care after release?
3. If 28% of persons in the US with HIV have suppressed
virus, what percentage of persons leaving jail can achieve
viral suppression at 6 months when linkage services are
available?
4. If models of excellence are now established in 20 jails
across the US, how do we transfer information to the
other 3200?

50. Poll
1. What percentage of HIV+ men in a jail population
acquired their infection through having sex with men?
a. 2% b. 6% c. 20% d. 40%
2. Is the presence of a serious mental illness in a jail releasee
associated with a higher or lower likelihood of
linkage/retention in care after release?
3. If 28% of persons in the US with HIV have suppressed
virus, what percentage of persons leaving jail can achieve
viral suppression at 6 months when linkage services are
available?
4. If models of excellence are now established in 20 jails
across the US, how do we transfer information to the
other 3200?

51. Poll
1. What percentage of HIV+ men in a jail population
acquired their infection through having sex with men?
a. 2% b. 6% c. 20% d. 40%
2. Is the presence of a serious mental illness in a jail releasee
associated with a higher or lower likelihood of
linkage/retention in care after release?
3. If 28% of persons in the US with HIV have suppressed
virus, what percentage of persons leaving jail can achieve
viral suppression at 6 months when linkage services are
available?
4. If models of excellence are now established in 20 jails
across the US, how do we transfer information to the
other 3200?

52. HOW DID EMORY/AID ATLANTA SUSTIN PROGRAM
AT FULTON COUNTY (GA) JAIL

53. RE-ESTABLISHMENT OF RAPID TESTING
CONTINUED LINKAGE SERVICES

54. Poll
1. What percentage of HIV+ men in a jail population
acquired their infection through having sex with men?
a. 2% b. 6% c. 20% d. 40%
2. Is the presence of a serious mental illness in a jail releasee
associated with a higher or lower likelihood of
linkage/retention in care after release?
3. If 28% of persons in the US with HIV have suppressed
virus, what percentage of persons leaving jail can achieve
viral suppression at 6 months when linkage services are
available?
4. If models of excellence are now established in 20 jails
across the US, how do we transfer information to the
other 3200?

55. CHALLENGES OF TRANSFERRING
INFORMATION

56. Jail linkage more imperative for HIV clinics than for jails
• Only 1-2 out of 100 inmates/releasees has HIV.
• 1 out of 6 persons with HIV in the US is in either a jail or a
prison at least part of the year.
Source: Spaulding, PLoS One 2009
Must keep in mind…

57. HERE IS A TYPICAL MEDIUM SIZED JAIL:
SPALDING COUNTY (GA)

58. CHALLENGES
AFTER ENHANCELINK
• Diffusion of information into non-grantee jails
• Finding champions within local jails
• Finding champions within local health departments
• Funding streams to underwrite programs
• Additional data to show cost-effectiveness of
jail/community linkage programs for HIV infected
detainees

59. Q&A
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