# Presentation: 525378

## HIV and Incarceration: Dual Epidemics

**HIV and Incarceration: ****Dual Epidemics**

**David Alain Wohl, MD**
***University of North Carolina***
***AIDS Research and Treatment Center***

## Incarceration fuels the HIV epidemic by:
Disrupting existing relationships 
Prompting risk behaviors in and out of prison

HIV care in most prisons and some jails is good but benefits accrued during incarceration are usually lost after relase

In the absence of a reduction in the incarceration rate of men and women at risk for HIV infection, the transition from prison/jail to community is the next best opportunity to reduce the contribution of imprisonment to the spread of the virus.

- Disrupting existing relationships
- Prompting risk behaviors in and out of prison
- HIV care in most prisons and some jails is good but benefits accrued during incarceration are usually lost after relase
- In the absence of a reduction in the incarceration rate of men and women at risk for HIV infection, the transition from prison/jail to community is the next best opportunity to reduce the contribution of imprisonment to the spread of the virus.

- HIV and Incarceration:

## In 1997, at least 1 of every 5 persons (>150,000 individuals) with HIV infection in the U.S. passed through a correctional facility (Hammett T, et al, 1997).   
The vast majority of persons who are incarcerated are released.  Mean duration of sentence is 2 years (US BJS).

- The vast majority of persons who are incarcerated are released.  Mean duration of sentence is 2 years (US BJS).

- HIV and Incarceration

## The arrest, incarceration and release of large numbers of HIV+ persons has a number of effects on the dynamics of the HIV epidemic:
Disadvantages:  
Incarceration is socially disruptive  
Removing a significant proportion of men from a community can foster behaviors associated with HIV transmission
In prison HIV transmission occurs but available data indicates it is not major source of HIV infection of inmates
Increased risk behaviors by the released inmate 
Increased risk behavior by the partner remaining in the community

- Disadvantages:
- Incarceration is socially disruptive
- Removing a significant proportion of men from a community can foster behaviors associated with HIV transmission
- In prison HIV transmission occurs but available data indicates it is not major source of HIV infection of inmates
- Increased risk behaviors by the released inmate
- Increased risk behavior by the partner remaining in the community

- HIV and Incarceration

## The arrest, incarceration and release of large numbers of HIV+ persons has a number of effects on the dynamics of the HIV epidemic:
Advantages:
Incarceration serves as a point of opportunity for HIV testing
Transmission risk reduction interventions can be applied in correctional settings
In-prison HIV treatment improves the health and potential productivity of the inmate during and possibly even after incarceration and reduces infectiousness 
Discharge planning linking the patient to community resources and services can, ideally, be achieved prior to release setting the stage for long term health care

- Advantages:
- Incarceration serves as a point of opportunity for HIV testing
- Transmission risk reduction interventions can be applied in correctional settings
- In-prison HIV treatment improves the health and potential productivity of the inmate during and possibly even after incarceration _**and**_ reduces infectiousness
- Discharge planning linking the patient to community resources and services can, ideally, be achieved prior to release setting the stage for long term health care

- HIV and Incarceration

## Discharge Needs 

- HIV+ inmates face a host of exigent needs following release
- Most are homeless
- >50% require on going mental health care
- Almost all need substance abuse counseling
- Job training
- Parenting classes
- On going HIV transmission risk reduction education
- All need HIV care

## Discharge Needs 

- HIV+ inmates face a host of exigent needs following release
- Most are homeless
- >50% require on going mental health care
- Almost all need substance abuse counseling
- Job training
- Parenting classes
- On going HIV transmission risk reduction education
- All need HIV care

## Prospective, observational cohort study of 170 HIV+ prison inmates (74% AA, 57% women)
Release=86, Recidivist=84

**Release=86, Recidivist=84**

**Study Design/Methods**

**PRE-RELEASE**

**POST-RELEASE**

**Within 3 months prior to release: **
**In-depth face-to-face interview regarding pre-incarceration HIV transmission risk behaviors **

**Asked to call study coordinator using toll-free pager 30-60 days following release:**
**Telephone interview concerning actual risk behaviors post-release**

**RECIDIVISTS**

**Released and now re-incarcerated**
**In-depth face-to-face interview regarding inter-incarceration HIV transmission risk behaviors**

## 	Post Release (mean 36 d after release)

**	**_***Medications***_
**	****Received ART supply at release****	****	****	****100%**
**	****Mean number of days of ART supply ****	****	****32d**
**	****Since release gone without HIV meds for >2d****	****17% **
***	***
***	***_***Access to Care***_
**	****Since release:**
**	****	****Not seen a health care provider ****	****	****41%**
**	****	****Health was better than when in prison****	****46%**
**	****	**

**Recidivists (mean duration free = 430 d)**
_***Medications***_
**Ran out of ART while free****	****	****	****34%**
**Mean time from release to running out of ART****	****159d**
**Mean length of time off ART while free****	****203d**
**	**
_***Access to Care***_
**Did not receive medical care while free****	****34%**
**Hospitalized between incarcerations****	****	****27%**
_***Strongly Agreed***_** or **_***Agreed***_** that after last release:**
**	****Covering medical costs was a problem****	****54%**
**	****Went without needed care because of expense 39%**
**	****I was able to get medical care when needed****	****62%**
**	****The clinic was conveniently located****	****	****65%**
_***Housing and Drugs***_
**Homeless, in a shelter or 1⁄2 way house while free ****	****31%**
**Using crack cocaine between incarcerations****	****	****75%**
**In drug rehab between incarcerations****	****	****	****32%**

- Wohl, et al. CROI 2004

## Unsafe sex among HIV+ prison releases

- High rate of unsafe sex especially among main partners
- Half of the partners were perceived by participant to be HIV uninfected
- One third of each group thought it somewhat or very likely they would infect a partner

- Stephenson B, Wohl D, et al. Int J STD AIDS. 2006** **

**Pre-Release**

**Post-Release**

## Viral Load Increases Among HIV+ Recidivists

**HIV-1 RNA (copies/ml)**

- Stephenson B, Wohl D et al 13th World AIDS Conf, Durban. 2000

## Slide 13

## What can be done to make transition successful?

- Limited comparative data on successful approaches
- Education (Motivational/Skill building – for HIV+ and HIV-)
- In prison/jail
- Post release
- Community partnership
- Need buy-in from community and leadership
- e.g. faith-based programs
- HIV Therapy – reduce viral load in genital secretions and therefore transmissibility
- Requires access to HIV care and medications post-release and adherence
- Inmates lose access to state ADAP
- New approaches to traditional case management

## Transition

- Case Management
- Comprehensive approach to coordinating social, medical mental health and other services
- ‘Glue’ that holds together a continuum of needed services
- In setting of HIV case management has:
- Increased access to benefits advocacy, psychological services, home health care and emotional support
- Discharge planning reduced **recidivism** from 39% to 17% in one year among women in RI; 72% to 49% in MA over two years (Flanigan et al, 1996, Skolnick et al, 1998)
- Higher utilization of health services and combination HIV therapy
- Improved health outcomes

## A Study of Bridging Case Management to Increase Access to Care and Reduce HIV Transmission Risk Behaviors Among HIV+ Former Inmates 

**BRIDGING CASE**
**MGMT (BCM)**

**I**
**N**
**T**
**A**
**K**
**E**

**Randomize**

**Evaluations:****<3m prior to release                ****	****Release  +14d    +2m    +6m    +9m  +12m**

**NCDOC Discharge Planning**
**(SOC)**

**A Study of Bridging Case Management to Increase Access to Care and Reduce HIV Transmission Risk Behaviors Among HIV+ Former Inmates **

## Bridging Case Management – Prelim Data

- 102 HIV+ participants enrolled
- 76% men, 81% African-American
- 75 participants have been released (median time out 138 days)
- Re-incarceration: SOC = 5, BCM = 1
- Utilization of ER for care:  SOC = 44%, BCM 28%
- Access to routine HIV care:

## Time to Access HIV Care

**Week 0****	****	****Week 2****	****	****Week 4****	****	****Week 8****	****	****Week 12**

**Proportion NOT in Care**** **

**100**
**90**
**80**
**70**
**60**
**50**
**40**
**30**
**20**
**10**

**P = 0.59**

**43%**

**21%**

## Communities of Origin

- Ratio of men to women is low
*Concurrency* of partnerships
- Available men often under-employed and often financially unstable
- Sexual mixing
- A substantial proportion of HIV+ African-American women have relatively few risk factors for infection (Adimora A et al, JAIDS 2006).

## Impact of Incarceration on Communities where HIV and Imprisonment are both Endemic

## Nexus between HIV and Incarceration

## Nexus between HIV and Incarceration

## Nexus between HIV and Incarceration

## Nexus between HIV and Incarceration

## wohl@med.unc.edu

- _[wohl@med.unc.edu](http://www.natap.org/)_