A 2019 In Practice/In ContextĂą„Âą Publication
THE EPIDEMICS OF HIV, HCV, AND HIV/HCV COINFECTION IN THE CORRECTIONAL SETTING
ISSUE 1
HIV UPDATES and INSIGHTS
REALITIES, CHALLENGES, AND OPPORTUNITIES TO IMPROVE CARE Jointly provided by Global Education Group and Integritas Communications.
In collaboration with the
This activity is supported by an independent educational grant from Gilead Sciences, Inc.
National Hepatitis Corrections Network
I CONTRIBUTORS AND EDITORIAL BOARD
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HIV UPDATES and INSIGHTS Matthew Akiyama, MD, MSc Editor-in-Chief
Dr. Matthew Akiyama is a physician-investigator whose research focuses on HIV and
Assistant Professor of Medicine
on the intersection of HCV in the criminal justice system. Dr. Akiyama is the recipient
Department of Medicine: Divisions of General Internal Medicine & Infectious Diseases Montefiore Medical Center
Albert Einstein College of Medicine Bronx, New York
Mandy Altman, MPA, CCHP Director, Correctional Health Program Hepatitis Education Project
National Hepatitis Corrections Network Seattle, Washington
hepatitis C virus (HCV) among socioeconomically marginalized populations, with emphasis of National Institutes of Health and institutional funding to develop and test innovative strategies to improve the HCV care cascade among justice-involved individuals and people who inject drugs. Dr. Akiyama is also active in correctional and community-based advocacy and leadership.
Ms. Mandy Altman is the director of the National Hepatitis Corrections Network (NHCN) and manages the prison and jail health education programs for the Hepatitis Education Project (HEP) in Seattle, Washington. HEP is a nonprofit committed to providing support, education, advocacy, and direct services for people affected by hepatitis and to helping raise hepatitis awareness among patients, medical providers, and the general public. Prior to her current position, Ms. Altman worked in correctional health education and global health.
Lara Strick, MD, MSc Clinical Associate Professor University of Washington
Infectious Disease Physician
Washington State Department of Corrections Tumwater, Washington
Dr. Lara Strick spends the majority of her time working as an infectious diseases physician for the Washington State Department of Corrections, providing care for patients with viral hepatitis, HIV, and other chronic infections. She is also cochair of the state prison systemâs infection prevention program, which includes a risk-reduction program to prevent new viral hepatitis and HIV infections, and Corrections Program Director for the Mountain West AIDS Education & Training Center. Dr. Strick provides corrections-based education and clinical training for medical students, residents, and providers.
Tracy Swan HIV and Hepatitis C Educator, Advocate, and Policy Advisor Brooklyn, NY
Alysse G. Wurcel, MD, MS Assistant Professor, Tufts Medical Center
Department of Medicine: Division of Geographic Medicine and Infectious Diseases Tufts University School of Medicine Department of Public Health and Community Medicine Boston, Massachusetts
Ms. Tracy Swan has worked in the fields of public health and social justice since 1990. She has been an outreach worker, headed an HIV counseling and testing program, designed HCV education and case-management services, and provided education at correctional facilities, community health centers, hospitals, syringe exchange and addiction treatment programs, and homeless shelters. Ms. Swan has also worked for Treatment Action Group and the MĂ©decins Sans FrontiĂšres Access Campaign, and has served on the US Food and Drug Administrationâs antiviral advisory committee, the AIDS Clinical Trials Group, and US-focused and World Health Organization HCV treatment guidelines panels.
Dr. Alysse Wurcel provides HIV and hepatitis C care at Tufts Medical Center as well as at four local county jails. She has received funding from the Center for AIDS Research and Tufts University to work on understanding barriers and facilitators to delivery of medical care to people in jail and people who use drugs. She is also co-investigator on a Tufts Clinical and Translational Science Institute (CTSI) Pilot project aimed at understanding HIV care transitions from jail to community.
HIV UPDATES and INSIGHTS I Target Audience This activity has been designed to meet the educational needs of correctional health care professionals who treat incarcerated persons with or at risk for human immunodeficiency virus (HIV) infection.
Educational Objectives Upon completion of this activity, participants will be better able to »» Describe epidemiologic trends in HIV within correctional institutions »» Provide opt-out HIV screening in accordance with current guideline recommendations »» Demonstrate knowledge of corrections-based HIV prevention and antiretroviral therapy (ART) »» Identify challenges to effective HIV treatment and prevention within the correctional setting
1
Program Description We, in the correctional community, have a critical part to play in shaping health care delivery and advocating for our patients. This is especially pertinent to HIV care, in which significant gaps in treatment and prevention persistâboth behind bars and upon community reentry. Across the corrections-based HIV-care continuum, from testing to harm-reduction practices to sustained viral suppression, providers encounter not only challenges, but also opportunities. This CorrectCare inPractice/inContext âą HIV supplement is intended to provide highly relevant educational content, best-practice principles, and real-world perspectives for corrections-based HIV care delivery and advocacy.
Disclosure of Conflicts of Interest
Nursing Continuing Education
Global Education Group (Global) requires instructors, planners, managers, and other individuals and their spouses/life partners who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations. The faculty reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity: Matthew Akiyama, MD, MSc No financial relationships to disclose Mandy Altman, MPA No financial relationships to disclose Lara Strick, MD, MSc No financial relationships to disclose Tracy Swan No financial relationships to disclose Alysse G. Wurcel, MD, MS No financial relationships to disclose
Global Education Group is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Centerâs Commission on Accreditation. This educational activity for 1.0 contact hour is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
Fee Information There is no fee for this educational activity.
Global Contact Information For information about the accreditation of this program, please contact Global at 303-395-1782 or cme@globaleducationgroup.com.
Disclosure of Unlabeled Use
The planners and managers reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity: Lindsay Borvansky Nothing to disclose Andrea Funk Nothing to disclose Liddy Knight Nothing to disclose Jim Kappler, PhD Nothing to disclose Ashley Marostica, RN, MSN Nothing to disclose Jeanette Ruby, MD Nothing to disclose
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration. Global Education Group (Global) and Integritas Communications do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity.
Accreditation Statement
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturerâs product information, and comparison with recommendations of other authorities.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Integritas Communications. Global is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation Global Education Group designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Creditâą . Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclaimer
Release date: March 8, 2019 Expiration date: March 8, 2020
INSTRUCTIONS TO RECEIVE CREDIT
After reading this supplement, please go to www.ExchangeCME.com/HIVCorrections to complete a short posttest. In order to receive credit for this activity, the participant must pass the posttest with a score of at least 70% and complete the program evaluation.
CLINICAL RESOURCE CENTER
For more resources and references, please visit www.ExchangeCME.com/HIVCorrectionsResources
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I HIV UPDATES and INSIGHTS
EDITORIAL AND SUPPLEMENT INTRODUCTION
Advancements and Opportunities: Stepping Up to HIV Matthew Akiyama, MD, MSc, Editor-in-Chief
The important lessons weâve learned from HIV are now being applied to the treatment of hepatitis C virus (HCV), and thereâs an interesting synergy between approaches to the two disease states. Attention has been focused over the last 4 years or so on the rapid acceleration of highly efficacious direct-acting antiviral (DAA) therapies for HCV treatment. Such attention has also highlighted DAA costs and cost-effectivenessâ and falling prices as a result of competition. These DAA considerations are now pointing to opportunities to ensure that the newest state-ofthe-art HIV therapies are brought onto corrections-based formularies at decreased cost and more quickly. Newer ARV regimens are associated with better rates of viral suppression, better tolerability, and lower rates of renal and bone toxicities. As we work toward improved access to these newer ARV regimens, we will need to establish ways in which the benefits of these medications can be extended into the community during and beyond the vulnerable reentry period.
Being equipped with up-to-date knowledge, we can investigate ways in which corrections-based HIV care can be at the forefront in providing state-of-the-art disease management. We, in the correctional health community, have a critical part to play in shaping health care systems and advocating for our patients in a multidisciplinary fashion. This requires being up-to-date on the scientific state of the art and the availability of new therapies, understanding the systems in which we operate, and having a real-world perspective on how correctional health care is ultimately embedded in the community. I strongly encourage collaboration internally as well as externally for clinical care, research, and continuing education. Being equipped with up-todate knowledge, we can investigate ways in which corrections-based HIV care can be at the forefront in providing state-of-the-art disease management. And, if thatâs not being done, we should question why not and advocate for best-practice care across the HIV care cascade in our own settings and beyond.
90
National average
Upon entry to jail/prison
During incarceration
After release
80 70
Total Persons, %
Weâre at a historic momentâa tipping point of sorts. Decades of tremendous work have gone into treatment and support of people living with HIV (PLWHIV), not only in medical advancements with high potency, well-tolerated antiretroviral (ARV) regimens, but also in terms of community-building and social advocacy. Such work has brought us to the point where HIV care can nowâat least potentiallyâbe successfully integrated within and at the interface of the correctional setting and the community. So, the spotlight is on what we as correctional clinicians, administrators, consultants, advocates, researchers, and educators can and will do to improve corrections-based and transitional care for PLWHIV.
Corrections-Based HIV Care Cascade1
60 50 40 30 20 10 0
HIV Diagnosed
Linkage to Care
Retention in Care
ART
Undetectable Viral Loads
It has been my pleasure to collaborate in the development of this CorrectCare HIV supplement with colleagues who bring a wealth of real-world expertise grounded in critical blends of medical science, psychosocial dynamics, advocacy, and policy-making. Recommended Initial ART Regimens for Most People With HIV 1 Lara Strick, MD, MSc, Clinical Associate Professor, University of Bictegravir/tenofovir alafenamide/emtricitabine Washington, and infectious diseases physician and educator with the Washington State Department aof Corrections, breaks down some of the Dolutegravir/abacavir/lamivudine : only for patients who are HLA-B*5701 negative challenges to providing comprehensive HIV care in prison settings. Addib tionally, she offers insights into patient readiness to engage in Dolutegravir/tenofovir /emtricitabine HIV care. Raltegravir plus tenofovir /emtricitabine Alysse G. Wurcel, MD, MS, Assistant Professor, Tufts University School Lamivudine may substitute emtricitabineCenter, or vice versa; of Medicine and TuftsforMedical discusses the feasibility of HIV Tenofovir alafenamide (TAF) and tenofovir disoproxil fumarate (TDF) are 2 approved forms of tenofovir. prevention in correctional settings. Bringing a public-health perspectiveFor and experience HIV and HCV care in jails, Dr.visit Wurcel fullextensive ART-prescribing guidelines, in including for previously treated persons, https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 addresses the HIV-prevention continuum tailored to the circumstances1 of this justice-involved population. b
a
b
Tracy Swan, HIV educator, advocate, and policy advisor, offers a critical perspective based in diverse community and international service and The Corrections-Based HIV-Prevention Continuum advocacy. She joins me for an interview regarding best practices for Community Interface of HIV care upon community reentry. Release and Reentry maintaining continuity Corrections Population I, Matthew Akiyama, MD, MSc, Assistant Professor of Medicine, Montefiore MedicalHIV Center, Albert Einstein College of Medicine, focus on delivery of care to marginalizedPEP populations from research, clinical, and HIV Treatment advocacy perspectives. Viral Suppression As Prevention
The tide for HIV medicine is rising and should carry all ships with it. Correctional health care, by virtue of resource limitations and other Condoms / NSP inherent challenges, can sometimes lag/ PrEP behind. But, I am hopeful, and I encourage you to be, as well. Positive developments in both HIV science and advocacy will allow us to continue to care for vulnerable and hardHIV: Nonvirologically Suppressed to-reach Key: populations. Leveraging correctional settings to provide and HIV: Virologically Suppressed sustain state-of-the-art HIV care for individuals coming from and returning NSP, needle and syringe programs Courtesy of Integritas Communications. to the community should be our goal. And I am confident weâre heading in the right direction.
Undetectable Equals Untransmittable (U=U)
1
1â6 Months to BECOME
6 Months
to STAY undetectable
Effectively No Risk of transmitting HIV
HIV UPDATES and INSIGHTS I
3
HIV-Care Challenges, Goals, and Strategies: Is Your Facility Ready to Step Up? Lara Strick, MD, MSc
Although it is not necessary to switch all patients who are doing
The provision of HIV care in the correctional setting can be as
well on an older regimen to one that is INSTI based, it is import-
simple as offering antiretroviral therapy (ART) or, it can encompass coordinated comprehensive care during incarceration, or
Corrections-Based HIVtoCare Cascade even integrate transitional planning ensure full community-re1
National and averagelinkage Upon entry jail/prison incarceration After release entry support to tocare. Many During facilities, often smaller
90
jails,80 still struggle with the sheer cost of HIV medications. This can70lead to numerous measures for âgetting aroundâ the cost Total Persons, %
including using an HIV diagnosis as a âget-out-of-jail-freeâ card, 60 or having officers fetch the patientâs previously prescribed medica50 tions 40 from his or her home. There are still facilities that present 30 patients with the full cost of their medical bills upon release from
the 20facility. Yet, while most providers and facilities attempt, at
side effects and lower pill burden, but also greater barrier to resistance.1 The more patients are given older, inadequate, or ineffective regimens, the more they will develop resistance, which in the end leads to more complicated and costly interventions.
The more patients are given older, inadequate, or ineffective
regimens, the more they will develop resistance, which in the end leads to more complicated and costly interventions.
This is critically important in a population that tends to go in
10 a minimum, to offer ARV medications in line with prevailing 0
ant to keep in mind that the newer regimens offer not only fewer
recommendations to treat all people living with HIV, without HIV Linkage Retention Undetectable
and out of systems and environments in which adherence may
ment outcomesâboth during and beyond incarcerationâneither
using a generic (for example, substituting generic lamuvidine for
Diagnosed
to Care
in Care
ART
1
Viral Loads
truly integrated psychosocial services that optimize HIV treatthe patientâs nor the systemâs interests are fully served.
Recommended Initial ART Regimens for Most People With HIV
emtricitabine), may not be worth the potential cost of losing viral suppression in less stable populations; and, as more generics come
1
onto the market, pill burden will likely increase. Importantly, these types of medication changes may significantly impact trust and the
Bictegravir/tenofovir alafenamide/emtricitabine Dolutegravir/abacavir/lamivudinea: only for patients who are HLA-B*5701 negative Dolutegravir/tenofovirb/emtricitabine
willingness of many patients to consistently take their medications. Offering an effective ART regimen is only the start. The readiness of a system or facility to provide adequate HIV care involves provision of that care in a wayâculturally and
Raltegravir plus tenofovirb/emtricitabine a
be negatively impacted. Further, the modest cost savings of
Lamivudine may substitute for emtricitabine or vice versa; Tenofovir alafenamide (TAF) and tenofovir disoproxil fumarate (TDF) are 2 approved forms of tenofovir.
attitudinallyâthat patients will accept. The justice-involved
b
patient population has a very high level of distrust, particularly
For full ART-prescribing guidelines, including for previously treated persons, visit https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 1
of the correctional medical system. Given the level of distrust
The provision of ART must start with an effective regimen. All
currently recommended initialHIV-Prevention ART regimens have a robust inteThe Corrections-Based Continuum grase strand transfer inhibitor (INSTI) as the backbone. Community Interface
HIV
Corrections Population PEP
Release and Reentry
and anger with the system, it is not unusual for patients to refuse medications, refuse care, and make choices that may be difficult to comprehend from the perspective of a medical professional. Allowing a patient to voice his or her frustrations and anger toward the often-oppressive system, and to potentially be the
4
I HIV UPDATES and INSIGHTS
recipient of that anger and frustration in order to get the patient to the point of HIV-treatment readiness, is sometimes a necessary part of providing care. Having patients sign a refusal-of-care form is an easy way to write off a patient, making it acceptable to no longer try to engage the
Establishing a healthy, trusting relationship between patient and provider may encourage patients to develop a consis-
tent habit of taking daily medications and foster an ongoing engagement in medical care upon release.
patient and absolving oneâs liability. In general, however, although I document when a patientâs choice may not be what I would choose, I continue to attempt over time to earn trust, understand the rationale behind the resistance, and get the individual to a point where he or she is ready to engage. Establishing a relationship and building rapport takes considerable time. In my experience, there have been patients for whom it has taken 6 months to a year of monthly visits just to achieve the level of trust needed to initiate ART and participate in their own care.
Historically, corrections-based HIV-treatment has focused on care provided during incarceration and, as such, the only outcomes considered were percentage of individuals screened, percentage treated, and percentage with a fully suppressed viral load at the time of release. Although published rates of viral suppression are better during incarceration than community rates for the same population, we can do better than the reported 60% to 70%.2,3 It is time for facilities to evaluate the reasons why the
Establishing trust can be further promoted by allowing patients to
other 30% to 40% are not suppressed prior to release and consid-
be autonomous in their care to the extent possible. This is particu-
er the UNAIDS 90â90â90 goals as target achievable in prison:
larly important in a correctional facility, where patients often have
That is, 90% of persons with HIV diagnosed, 90% of those diag-
very little control over their daily lives. Allowing patients to make
nosed on treatment, and 90% of those on treatment virologically
their own choices often results in the buy-in necessary for patients
suppressed.4,5 Many facilities are starting to develop and imple-
to take ART consistently and engage regularly. From choosing a
ment quality-improvement programs to evaluate HIV care in
medication regimen to how it is dispensed (self-administered vs
their facilities. Simply evaluating rates of HIV testing upon entry
pill line/directly observed), I let the patient decide. This requires
and rates of viral suppression at the time of release are easy places
both a certain degree of educational intensity and respect for the
to begin assessment of a facilityâs HIV-care cascade.
patient as an autonomous, empowered person.
Multiple studies have shown that despite gains in HIV care
Although incarceration should not be thought of as an opportu-
during incarceration, maintaining those gains postrelease is an
nityâit is the worst opportunity we could offer anyone, despite
enduring challenge.2,3 Effective, collaborative, reentry planning
guaranteed housing and foodâit is a time when many patients
and transition support begins during incarceration and needs
achieve a suppressed viral load for the first time. The extremely
to be sustained within the community. A later article in this
structured lifestyle and the elimination of many of the stressors
supplement will address transitional care for people living with
that accompany community life gives many individuals the ability
HIV [page 8].
to prioritize their medical care in ways that they have never been
The overwhelmingly punitive culture that impacts mental health
able to do before. Establishing a healthy, trusting relationship between patient and provider may encourage patients to develop a consistent habit of taking daily medications and foster an ongoing engagement in medical care upon release. From a facility perspective, providing standard-of-care HIV treatment with the use of current highly effective ART regimens is an âopportunityâ to avoid acute-careâhospitalization costs related to the untreated opportunistic infections that we used to routinely see.
and chemical dependency treatment of justice-involved patients needs to be addressed when developing both in-facility and transitional programs. The expansion of community mental health services is slowly diverting patients away from the legal system, though not quickly enough. Similarly, medication-assisted treatment for opioid use disorder is gaining acceptance, and its slow incorporation into criminal justice systems may avoid incarcerating folks with addiction.6 However, when discussing patient
HIV UPDATES and INSIGHTS I
5
success in this regard, there is a tendency to define success in very
ago, at which time he switched to smoking meth as his only mode
narrow terms limited to absolutes, like total abstinence. I consider
of use. But Mr. T remains housed after 15 years, he has never
many of my patients to be success stories, like the following, which
again been arrested or returned to prison and has been able to
you may not initially recognize as such. My long-term patient,
lead a good life outside of the correctional setting: A clear success.
Mr. T, had over 30 felony convictions and had spent most of
So, what is success, and in what terms do we measure it? Harm
his life in prison. When I first saw him, he had never previously
reduction, a set of principles and practices that recognizes the
engaged in medical care and his CD4 cell count was in the single
enduring reality of drug use and the humanity of those who use
digits. With some encouragement, Mr. T started consistently
drugs, may help answer this question.7
taking his ART and had an undetectable viral load upon release.
Is your correctional facility ready to step up to providing opt-out
He was placed in stable long-term community housing, but this did not mean he did not have ongoing struggles. There were still times when he would go off his HIV medication, as when his grandmother died. And, he continued to intermittently inject methamphetamines until he developed a hip infection two years
testing for HIV,8 nonjudgmental HIV care during incarceration, comprehensive linkage to HIV care upon release, and ongoing community interventions to promote long-term retention and viral suppression? If so, we are likely to have more success stories like Mr. T.
Key Harm-Reduction Principles, Practices, and Strategies 7 Reducing the Negative Consequences of Injection Drug Use PRINCIPLES
PRACTICES AND STRATEGIES
»» Accepts, for better and for worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them
»» Medication-assisted treatment (MAT)
»» Understands drug use as a complex, multifaceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others »» Establishes quality of individual and community life and well-beingânot necessarily cessation of all drug useâas the criteria for successful interventions and policies »» Calls for the nonjudgmental, noncoercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm
»» Needle and syringe programs (NSP) »» Combined mental health services/MAT/NSP »» Recognition of nonviral infections and medical consequences of injection drug use »» Harm reduction as HCV prevention: infection and reinfection »» Information, education/counseling, and outreach
Adapted from Harm Reduction Coalition.7
Corrections-Based HIV Care Cascade1
6
I HIV UPDATES and INSIGHTS National average
90
Upon entry to jail/prison
During incarceration
After release
80
Total Persons, %
70 60
Is HIV Prevention Feasible in the Correctional Setting? 50
40
30
20 10 0
HIV Diagnosed
Linkage to Care
Retention in Care
ART
Undetectable Viral Loads
Initial ART Regimens forneeds MosttoPeople HIVno amount of education or counseling First, however, HIV stigma be Withbut Alysse G. Wurcel, MD, MS Recommended 1
addressed. Recently, during two separate alafenamide/emtricitabine Proactive testing and treatment areBictegravir/tenofovir patient interactions, I was reminded of its crucial to containment and elimination of
could change his mind. He told me that during a previous time in jail, a nurse had
Dolutegravir/abacavir/lamivudinea: only for patients who are HLA-B*5701 negative
infectious disease epidemics. The overlay
demoralizing impact. In the first encoun-
ter, a bwoman recounted that after I had Dolutegravir/tenofovir /emtricitabine of critical social determinants of health deliveredb the diagnosis of HIV to her, makes this especially true. Homelessness, Raltegravir plus tenofovir /emtricitabine
called out across a common space, âHere are your HIV meds.â He was scared that he would be the target of bullying and
she told her cellmates. They subsequently even life-threatening encounters were his poverty, and criminal justice involvea Lamivudine may substitute for emtricitabine or vice versa; refused do her laundry, HIV diagnosis known or made public. b Tenofovir alafenamide (TAF) andto tenofovir disoproxil fumarateshare (TDF) areutensils, 2 approved forms of tenofovir. mentâcompounded by substance use or sit on the same toilet seat. With the These two real-life experiences highlight disorder, mental illness, and other medical For full ART-prescribing guidelines, including for previously treated persons, visit compounding emotional toll of isolation that stigma against people with HIV is 1 https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 comorbiditiesâcontribute to the spread of imposed by the jail environment, my
infectious epidemics. All infections, however, are not given the same
still alive and flourishing despite remark-
The Corrections-Based HIV-Prevention Continuum
able advances in HIV treatment and prevention.
Some jails do, in fact, have a mandatory âHIV 101â most jails and prisons have Corrections Population course upon entry and this well-defined, comprehenHIV education may help reduce PEP sive protocols for identifear and stigma surroundHIV Treatment fication, quarantine, and Viral Suppression ing HIV. Importantly, it As Prevention treatment of people who also provides opportunimay have active tuberties to request testing. To Condoms / PrEP / NSP culosis (TB). Yet, policies date, however, there is no for prevention of HIV in standardized requirement correctional settings are Key: HIV: Nonvirologically Suppressed for such education, or HIV: Virologically Suppressed often suboptimal. Iâll briefstandards for measuring NSP, needle and syringe programs Courtesy of Integritas Communications. ly discuss some barriers its success. There is strong and opportunities to offer evidence, however, patient soon reached a level of despair 1 Undetectable Equals Untransmittable (U=U) that education is crucial to breaking down people in jail and prison improved access necessitating emergency psychiatric treatpersistent stigma and promoting sensitive, to both HIV treatment as prevention and 1â6 Months Effectively No Risk ment. I also saw 6a Months man living with AIDS and effective HIV-care delivery.1 primary prevention options. to BECOME to STAY undetectable of transmittingmindful, HIV who, upon reincarceration, refused to undetectable after after ïŹrst undetectable to a sex partner attention. For example,
Community Interface
starting treatment
Release and Reentry
test result
take ART. He had a low CD4 cell count, As long as HIV remains
RISK
undetectable: ART should be taken daily Viral load should be monitored regularly
· ·
HIV UPDATES and INSIGHTS I
7
At the population level, HIV testing,
populations. It behooves all facilities to
selves against HIV acquisition. This may
treatment, and viral suppression reduces
have a PEP evaluation plan that can be
be especially important in corrections, as
the local viral reservoir that extends from
implemented within 72 hoursâif not
some sexual encounters may be repeated
the correctional setting into surrounding
soonerâto assess and medically intervene
and nonconsensual.
communities. And, now, with the advent
following high-risk exposures.
of once-daily, low-toxicity ARV regimens,
Although PrEP currently receives little
From PEP, we move to evidence-based
support in closed correctional settings,
harm-reduction measures for preventing
effective HIV screening protocols and
HIV transmission before an at-risk event.
PrEP provision upon release from a
But, as sexual activity is not permitted in
correctional setting is a critical opportuni-
jails or prisons, corrections administrators
ty for prevention, as this is a particularly
express concern that any form of harm
vulnerable time when people are at risk
reduction, including condoms and HIV
for acquiring HIV.9
when individuals receive a diagnosis of HIV, the goal is to get these patients on treatment and undetectable as soon as feasibleâbenefiting the individualâs health and preventing HIV transmission. Clearly, treatment as prevention is an important aspect of HIV care in correctional settings.2 Still, however, missed opportunities for HIV diagnosis remain common. I saw a man in jail who lost half his body weight over several months. Once the HIV diagnosis was made, we learned that his CD4 count was less than 10 cells/”L. This one example underscores the need for HIV testing as an integral part of the corrections intake process, in line with the Centers for Disease Control and Prevention recommendation for corrections-based HIV opt-out testingâan approach that can destigmatize testing and normalize it as a part of routine medical care.3
preexposure prophylaxis (PrEP), will facilitate an increase in risk behaviors. They often point to blurred lines between consensual sex, exchange sex, and rape, especially when sex is being offered in exchange for food, drugs, or physical protection. And, further, although needle
HIV prevention is indeed feasible within the correctional setting, but we may have a ways to go in achieving this goal.
and syringe programs (NSP) are evidencebased interventions that decrease disease transmission in the community, provision of clean needles inside the jails and prisons has received little support nationally. International programs and limited US pilot studies may provide the tools needed to convince criminal-justiceâsystem stakeholders that availability of harm-re-
HIV prevention is indeed feasible within the correctional setting, but we may have a ways to go in achieving this goal. The criminal justice system is the touchpoint for people with HIV infection who may have limited access to servicesâand, who often have no trust in the health care system. Moving forward, we should
The next step in the HIV-prevention
duction education and toolsâcondoms,
continuum from treatment of known
PrEP, NSPâwithin corrections settings
disease to prevention of new cases is HIV
may minimize spread of HIV and other
postexposure prophylaxis, or PEP.4 There is
sexually transmitted and blood-borne
evidence to support the efficacy of ARV
infections without the feared outcome of
medications for postexposure prevention
increased sex.5,6,7
of HIV acquisition in circumstances
The once-daily, single-tablet, ARV regi-
and evidence, we can improve access
men of emtricitabine/tenofovir disoproxil
to a complementary array of effective
fumarate has been FDA-approved for
HIV-prevention measures for people in
use as PrEP to prevent HIV transmission
jail and prison.
involving blood exchange or sexual assault (especially, anal intercourse). Prompt intervention and evaluation is necessary, even if involved persons refuse testing, given the high prevalences of HIV and hepatitis B and C viruses in jail and prison
through sexual activity and sharing of injection equipment.8 PrEP provides a way for individuals to effectively protect them-
push for opt-out testing coupled with HIV treatment-as-prevention initiatives, mandated PEP policies, and pilot projects to assess feasibility of PrEP delivery for these individuals under our care. Working collaboratively, with empathy, innovation,
8
I HIV UPDATES and INSIGHTS
JOINT INTERVIEW BY INTEGRITAS COMMUNICATIONS
Best Practices for Maintaining Continuity of HIV Care Upon Community Reentry: Goals and Roles Matthew Akiyama, MD, MSc Editor-in-Chief
Tracy Swan
TS: Itâs really important to focus first on establishing trust. Starting transition planning early is so important for building connections with a person before everything in their life shifts. Itâs
HIV and HCV Educator, Advocate, and Policy Adviser
good for the individual to have a few peopleâanchorsâwhom
INTEGRITAS: When should reentry preparation start for
be frustrating. Some people are not familiar with how to talk with
individuals receiving HIV care in the corrections setting? MA: Community reentry preparation should start very soon after incarceration, especially when a short stay is anticipated. In an ideal world, a medical visit is obtained within 24 hours of intake. The medical provider should be prepared with questions about the patientâs community-based HIV care. This will inform the HIV management plan in the correctional setting, as well as the transition back to community-based care. In the context of a longer prison stay, planning ideally begins 60 days or more ahead of anticipated reentry, though this will depend on reentry needs. As the individualâs community health care circumstances may have changed dramatically, we need to make sure the patient
they trust enough to reach out to, since accessing health care can providers who have limited time, or donât know that they may wind up having to wait for quite a while. And, as Matt mentioned, housing is a huge concern: Having a place to land can be an immense hurdle, because in some jurisdictions people who have been convicted of a felony do not have access to public housing. Access to mental health care can also be very challenging because of provider shortages. And, since itâs common for people to start using drugs once theyâve left the corrections setting, the abstinence requirements of some programs can exclude people who may be motivated to access themâleaving them shut out of vital services. This underscores the importance of referring individuals to syringe services and medication-assisted treatment.
is lined up with appropriate HIV care, and this may require
MA: Thereâs a vast shortage of mental health care, and thatâs
significant lead time. We should also try to address all the social
a big problem. Providing longitudinal mental health care in
determinants of healthâespecially housingâas they go hand-
the community can potentially have impact on reducing risks
in-hand with the clinical aspects of HIV care. Thatâs why itâs so
of reincarceration. The same goes for drug treatment. But as a
important to have multidisciplinary teams: Ideally community
by-product of recent response to the opioid crisis, increasingly
health workers or social workers, and sometimes peer educators,
more drug-treatment programs and incarceration-alternative
will be involved in collaboratively formulating and executing a
programs are emerging. This landscape is heterogeneous, with
discharge plan. It is important for medical providers to attempt
a variety of models from abstinence-based to low-threshold
to sit down with patients and these providers to truly understand
harm-reduction approaches.
the needs of the patient. Patient-, institutional-, and community-level barriers to the individualâs successful reentry can then be
TS: When considering these and other community-based services, itâs important to identify and select support services providers and
proactively identified and addressed by the interdisciplinary team.
people within organizations who are comfortable working with
If we donât forge these relationships between the community and
people who use drugs. This applies to some medical providers, as
the correctional setting, the patients that we care for suffer for our
well, because this is an area in which clinicians typically donât get
lack of doing so.
adequate training.
For full ART-prescribing guidelines, including for previously treated persons, visit https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 1
HIV UPDATES and INSIGHTS I
9
The Corrections-Based HIV-Prevention Continuum
Community Interface
HIV
Corrections Population
Release and Reentry
MA: One thing that Iâve become more aware of is that while itâs
MA: This ties in with how individuals can take responsibility
helpful for some former detainees to work with a peer who has a
for protecting themselves and their partners from risk of HIV
shared history of incarceration or a shared disease history, some
transmission. It entails understanding that undetectable equals As Prevention
people feel like once theyâve come home they donât want to be
untransmittable (U=U) and contextualizing it in personal terms
HIV Treatment
PEP
Viral Suppression
associated with anything that reminds them of incarceration.
Condomsof/ education-driven PrEP / NSP of self-efficacy. Another example self-care
Tailored approaches to the individual are critical, since this is a
is understanding the benefits of sustained ART, beyond those of
very vulnerable time.
viral suppression and prevention of AIDS-related events. The Key: HIV: Nonvirologically Suppressed
INTEGRITAS: What would you consider the minimum
real-world expectations for continuity of HIV care upon community reentry? MA: From a medical perspective, I think everyone should have
Suppressed cardiovascular HIV: andVirologically neurologic benefits of ART are critical to NSP, needle and syringe programs
overall health and well-being.
Undetectable Equals Untransmittable (U=U)
1
1â6 Months
to BECOME undetectable after starting treatment
a written document, be it a provider note or a care summary, with exactly what has taken place during the period of incarcera-
6 Months
to STAY undetectable after ïŹrst undetectable test result
tion. This is similar to a hospital discharge summaryâincluding medications, lapses in adherence and their reasons, vaccinations, and other information that should follow that patient into the community. It is often quite difficult for detainees to access their medical records. And, with transitions in and out of corrections,
Courtesy of Integritas Communications.
RISK
Effectively No Risk of transmitting HIV to a sex partner
As long as HIV remains undetectable: ART should be taken daily Viral load should be monitored regularly
· ·
Undetectable Adapted from: Minnesota Department of Health. http://www.health.state.mn.us/divs/idepc/diseases/hiv/uu/index.html
there may be glitches in communication resulting in discontinuity of care. This is a good example of the need for patient education and self-advocacy.
If we donât forge these relationships between the community and the correctional setting, the patients that we care for suffer for our lack of doing so.
TS: People, at a minimum, need a care planâsomething in
INTEGRITAS: Looking forward, what emerging trends in transition services for people living with HIV would you like to see become the standard of care? TS: There are some community models that are localized, but
scalable, such as Rhode Islandâs (RI) Project Bridge, a partnership between an academic institution, community-based organizations, and the RI Department of Corrections.2 The HIV care providers establish relationships by visiting people while they
writingâand they need ways to connect with people listed in
are detained, and then seeing them in the community. Another
their care plan, including email addresses and phone numbers.
example of this type of model is New York Cityâs Transitional
You may even want to ensure that they have money for access to
Health Care Coordination.3,4 But the current US mass incarcer-
a phone or computer. There are other pragmatic concerns, areas
ation rates merit a hard systems-based look at what will be most
where peer educators and navigators from the outside are so
effective for getting people linked, engaged, and retained in care
important for addressing transitional needs.
on a larger scale.
If people have information they can self-advocate, but they really need to know what to fight for, as well as how to fight for
MA: Iâll echo the need for systems-level changes, some of which could include corrections/community networks. In addition
it. Self-advocacy is all about your own healthâno one is going
to the programs you mentioned, there is a similar Hampden
to fight for it the way that you will. It is knowing that you have
County [Massachusetts] model in which community physicians
the right to health and the right to information. The best services
see patients while they are incarcerated in order to establish and
offer support, while encouraging autonomy.
maintain continuity of care.5
10
I HIV UPDATES and INSIGHTS
These programs can be thought of as the inside looking out. But,
TS: I think we will see much less of a singular focus on viral load
thereâs also the outside looking in perspective. This may take the
suppression. The bottom line is facilitating a more secure footing
form of corrections-based transitions clinics that are sensitive to
in the world for people, so that they can access the health care
the needs of former detainees reentering the community. Together
and support services that they need.
with networks of clinics in the community, the benefits of wraparound discharge planning services can be extended into the community. Widespread adoption of these models would represent an important systems-level change.
REFERENCES Advancements and Opportunities: Stepping Up to HIV 1. I roh PA, et al. The HIV care cascade before, during, and after incarceration: a systematic review and data synthesis. Am J Public Health. 2015;1057:e5-e16.
HIV-Care Challenges, Goals, and Strategies: Is Your Facility Ready to Step Up? 1. United States Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Last updated May 2018. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0. Accessed October 18, 2018. 2. Costa M, et al. Assessing the effect of recent incarceration in prison on HIV care retention and viral suppression in two states. J Urban Health. 2018;95(4):499-507. 3. Loeliger KB, et al. Predictors of linkage to HIV care and viral suppression after release from jails and prisons: a retrospective cohort study. Lancet HIV. 2018;5(2):e96-e106. 4. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-90-90: An ambitious treatment target to help end the AIDS epidemic. 2014. http://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf. Accessed October 18, 2018. 5. Centers for Disease Control and Prevention (CDC). Understanding the HIV care continuum. 2018. https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf. Accessed October 18, 2018. 6. Mattson CL, et al. Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016âJune 2017. MMWR Morb Mortal Wkly Rep. 2018;67(34):945-951. 7. Harm Reduction Coalition. Principles of harm reduction. https://harmreduction.org/ about-%20us/principles-of-harm-reduction/. Accessed October 18, 2018. 8. CDC. HIV testing implementation guidance for correctional settings. 2009. https://stacks.cdc. gov/view/cdc/5279. Accessed October 18, 2018.
Is HIV Prevention Feasible in the Correctional Setting?
1. Valera P, et al. HIV risk inside U.S. prisons: a systematic review of risk reduction interventions conducted in U.S. prisons. AIDS Care. 2017;29(8):943-952. 2. Beckwith CG, et al. Opportunities to diagnose, treat, and prevent HIV in the criminal justice system. J Acquir Immune Defic Syndr. 2010;55(suppl 1):S49-S55.
3. Centers for Disease Control and Prevention (CDC). HIV testing implementation guidance for correctional settings. 2009. https://stacks.cdc.gov/view/cdc/5279. 4. Jain S, Mayer KH. Practical guidance for nonoccupational postexposure prophylaxis to prevent HIV infection: an editorial review. AIDS. 2014;28(11):1545-1554. 5. Torriente A, et al. Opening the door to zero new HIV infections in closed settings. Health Hum Rights. 2016;18(1):157-168. 6. Rubenstein LS, et al. HIV, prisoners, and human rights. Lancet. 2016;388(10050):1202-1214. 7. Lucas KD, et al. Evaluation of a prisoner condom access pilot program conducted in one California state prison facility. 2011. http://online.wsj.com/public/resources/documents/pilot. pdf. Accessed October 18, 2018. 8. CDC/US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States__2017 Update. 2017. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hivprep-guidelines-2017.pdf, Accessed October 18, 2018. 9. Brinkley-Rubinstein L, et al. The path to implementation of HIV preexposure prophylaxis for people involved in criminal justice systems. Curr HIV/AIDS Rep. 2018;15(2):93-95.
Best Practices for Maintaining Continuity of HIV Care Upon Community Reentry: Goals and Roles
1. Minnesota Department of Health. Undetectable = Untransmittable (U=U). 2018. http://www. health.state.mn.us/divs/idepc/diseases/hiv/uu/index.html. Accessed October 18, 2018. 2. Wakeman SE, et al. HIV among marginalized populations in Rhode Island [Project Bridge]. Med Health R I. 2009;92(7):244-246. 3. City of New York. NY Health. Transitional Healthcare Coordination. 2018. https://www1. nyc.gov/site/doh/health/health-topics/transitional-healthcare-coordination.page. Accessed October 18, 2018. 4. Jordan AO, et al. Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island. AIDS Behav. 2013.17(suppl 2):S212-S219. 5. Hampden County Sheriffâs Department. Hampden County Correctional Center. 2018. http:// hcsdma.org/. Accessed October 18, 2018.
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