SMART TA

Management of HIV in prison

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Good prison health is good public health

“EVERY YEAR, MORE THAN 30 MILLION PEOPLE WORLDWIDE ENTER AND LEAVE PRISON SYSTEMS

AND REJOIN THE COMMUNITIES”

Good prison health is good public health:

Outline

1. HIV in prisons setting2. Principle on management of HIV in prison

and jails3. Lesson learned of HIV care and treatment in

prison4. Recommendations5. Key points

1. HIV in prison setting

VN is the second highest HIV prevalence in prison

Facts and figures

Source: HIV and AIDS in places of detention (WHO 2008) – những con số biết nói

US HIV Data: Prisons and General Population

• State and federal prisons (2004)– HIV prevalence among

the prison population was 4 to 5 times that of the general population

Maruschak LM. Bur Justice Stat Bull. November 2006.Available at: http://www.ojp.usdoj.gov/bjs/abstract/hivp04.htm.

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HIV Prevalence

Prev

alen

ce (%

)

All Prisoners(State and Federal)

98 99 00 01 02 03 04

General Population

Year

Why Are PLWHA in prison Important Targets for Intervention?

Most HIV (+) intimates are infected before they enter prisonHIV-infected persons are frequently diagnosed and initiate

antiretroviral therapy in prison

Prison68%

Other setting32%

Mostashari F, et al. JAIDS. 1998;18:341-348.

Co-morbidity Conditionsin the Incarcerated Population

• Mental illness– Up to 50% have axis 1 or 2 mental disorders

• Substance abuse- As many as 75% have alcohol and/or other substance abuse disorders

• Tuberculosis- 40% of Americans intimate with active tuberculosis

• STDs• Hepatitis, especially HCV

– 1.3 to 1.4 million inmates are HCV+– Prevalence of HCV in inmates 10x that of US population– Incarcerated women have a higher rate of HCV than incarcerated

menDeGroot A. HEPP News. April 2001; Baillargeon J, et al. Public Health. 2003;117:43-48.

HIV in prison setting - the fact:

• The rates of HIV infection in prisons are 5-7 times higher than those in the general population

• Up to ¼ the HIV-positive population of a country pass through prisons

• HIV fueled by injecting drug use, 5-10% of new HIV infections attributed to drug use, many IDUs periodically incarcerated.

• Prisons are key points of contact with millions of individuals living with or at high risk of HIV infection, who out of reach of the medical system in the community

Source: HIV and AIDS in places of detention (WHO 2008) HIV in place of detentions: module 5 for prison health staff. P. 119HIV in prison and jail. Factsheet 615

HIV in prison setting - the fact:

• Health services in prison are substandard and under-funded, lack of HIV preventive services, isolated from general health system hamper quality and continuum of care

• Some facilities have no health care provider who know about HIV care

• Prison conditions contribute to the spread of HIV also influence HIV treatment

HIV in prisons and jails. Fact Sheet Number 615. www.aidsinfonet.orgHIV and AIDS in places of detention (WHO 2008)

Factors assosiated with HIV prevalence in prison

• Overcrowding: – Prisons are overcrowded in 111 countries;

– Prisons in 39 countries housing 1.5 to 3 times capacity

• Violence, self harm• Higher prevalence of drug use, HIV, hepatitis B and C, TB, mental

illnesses than in society outside • Vulnerable groups/behaviour:

– Hierarchical homosexual relations

– Other forms of sexual violence e.g. gang rape

– Tattooing

– Drug use, including injecting drug use (IDU)

Proportion of Drug Users among Prisoners in Europe

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Country Proportion of drug users amongprison population (minimum)

Country Proportion of drug users amongprison population (maximum)

Source: Dr. Stoever, 2004

Challenges to HIV Care and treatmentin Prison• Lack of HIV specialists, integrated delivery systems,

community standard practices• Remote locations • Continuity of care • Mistrust and stigma• Language/cultural barriers• Restricted formularies• Confidentiality/privacy

Factors influence HIV care and treatment in prison and jail• Prior treatment history• Current viral load and CD4 levels• Resistance to medications • Other health issues, such as injection• Drug use mental health• Problems, liver disease, and diabetes• Patient preferences• Length of prison term• Medication timing relative to inmate activities, food

requirements, and refrigeration

Health facility in prison in Vietnam

• Most prison medical centers do not have any of the facilities as required for HIV routine care (blood test, X-ray…) and it is not practical or cost effective to send every prisoner who requires a blood test to the hospital for care

• Prison facilities usually have facilities equivalent to the commune level (in equipment, staffing etc) except that:– They deal with a range of medical problems equivalent to the district or

provincial level with limited facility and face difficulties in making referrals difficult cases

– Each staff much deal with the full range of conditions, multi-tasks

Health facility in prison in Vietnam

• Structural factor: close setting, overcrowding, inadequate health care

• Follow-up after release is very poor with most patients not successfully engaging in care after release:– Risk of ARV resistance– Risk of acute Hep B and HIV illness after stopping treatment– Possible INCREASED risk of transmitting HIV at a time that they might be

having more risk behavior than usual (sexual behavior, relapse of drugs use)

• Equivalent to district TB unit:– Limited diagnostic capacity (but enough to cover most cases)– Structured assessment and referral– DOTS– Supervision from provincial unit

2. Principle of HIV management in prison and jails

In 1993 WHO issued guidelines on HIV infection and AIDS in prisons…

“All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status or nationality. The general principles adopted by national AIDS programs should apply equally to prisoners and to the community.”

A WHO guidelines on health in prisons

• Standards in prison health: the prisoner as a patient• Primary health care• Communicable diseases• HIV infection• Tuberculosis control • Drug use and drug services, Substitution treatment• Mental health• Dental health• Special health requirements for female prisoners• Promoting health and managing stress among prison staff

HIV/AIDS in prison settings … warrants a comprehensive approach• Advocacy to mitigate problem of governmental denial & to

create favourable legal / policy environment

• HIV/AIDS prevention, care and treatment in prison settings equivalent (the same) to outside community

• Improvement of general prison conditions by⁻ Minimizing overcrowding (e.g. use of alternative measures and

diversion programs)

⁻ Operating secure, safe and orderly prisons

⁻ Reducing violence

• Continuity of care: linkage from prison to community care, comprehensive approach to support when prisoner are released

UN Technical guidance on HIV care and support in prison: 15 key interventions1. Information, education and communication2. Condom programs, 3. Prevention of sexual violence4. Drug dependence treatment, including opioid substitution

therapy5. Needle and syringe programs6. Prevention of transmission through medical or dental

services7. Prevention of transmission through tattooing, piercing and

other forms of skin penetration

HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of intervention, UN June 2013

UN Technical guidance on HIV care and support in prison: 15 key interventions

8. Post-exposure prophylaxis

9. HIV testing and counseling

10. HIV treatment, care and support

11. Prevention, diagnosis and treatment of TB

12. Prevention of mother-to-child transmission of HIV

13. Prevention and treatment of sexually transmitted infections

14. Vaccination, diagnosis and treatment of viral hepatitis

15. Protecting staff from occupational hazardsHIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of intervention, UN June 2013

PLWHA Enter Prison Offer HIV testing

PLWHA Declares Status or

Accepted HIV TestingHIV Testing

Linkage to Care&Treatment /

Discharged Planning

PLWHA Released from Jail

Intensive Case ManagementLinkage and Engagement in HIV

Care in Community

Primary Care Service Other support: Mental Health, Substance Use, Social Support

HIV intervention in Prison logic model (proposed)

UN Technical guidance on HIV care and support in prison

• Needle and syringe program & decontamination strategies

• Prevention of sexual transmission• Drug dependence treatments• HIV care, treatment and support

4 key interventions documented to be effective

US Prison data: HIV cases and AIDS

related deaths decreased by time

HIV treatment in Prison equivalent

to community (US Prison data)

Source: Bureau of Justice Statistics, Deaths in Custody Reporting Program and National Prisoner Statistics-1 data collections;

Center for Disease Control and Prevention, HIV/AIDS Surveillance.

Goals of ART Therapy and Tools to Achieve

GOALS Maximal and durable

suppression of viral load.

Restoration or preservation of immunologic function..

Reduction of HIV-related morbidity and mortality.

Improvement in quality of life

TOOLS Maximize adherence to the

antiretroviral regimen.

Rational sequencing of drugs.

Reservation of future treatment options

Early detection and adequate management of treatment failure.

Linkage and Engagement in HIV Care in Community

Principles of HIV treatment in prison

• Prisoners bring information with them (education for patient):– HIV medications– CD4 cells counts and viral load– HIV related illness– Side effects

• Adherence: build trust and acceptance of ART, reduce institutional barriers to adherence

• Administration of treatment– When to start– What regimen to use

• Simplicity, dosing, frequency, side effect profile, drug interactions– ARV under direct observation, – Modified directly observed therapy (DOT)—significant better results

• Planning for continuity of care from the outset

Antiretroviral Therapy in Prison Settings

• Structured setting• Equal access to care• Availability of ART• Possible DOT

• Continuity of care• Transfers• Potential breach of

confidentiality• “Unstructured” DOT• presence of mental

illness

Advantages Disadvantages

3. Lesson learned

From evidence to actions: Thailand Experiences

• Interventions:– Prevention for IDUs– HTC– HIV care and treatment: OIs, adherence, TB and ART, peer support system,

volunteer• Challenges:

– Stigma and discrimination– Discourage from taking medicines in crowded environment– Mistrust of prison staff– Transfer to other facilities– Poor social support upon release

• Solutions:– Positive attitude of health staff– Referral to hospital when needed– Plan for continuing treatment before release– Medication supply for three months before enroll in the community ART

program

From evidence to actions: Indonesia Experience

• HIV prevalence in prison 15%• Policy advocacy and system strengthening:

– A public health approach for prisoners (2006) - National Action Plan for HIV and AIDS Control in Prisons and Detention Centers, 2010 to 2014:

• Inter-sectorial collaboration: MOH, Ministry of Law and Human rights, NGO and local stakeholders

– Collaboration with health care provider for specialized medical care– MoU and collaboration between prison and District hospital, primary health

care and TB unit were signed

• Intervention– Essential health care service: TB, HIV, MMT in prisons, Harm reduction– Trust building, compliance to HIV prevention and care and peer group– HIV care and treatment: treatment daily under direct supervision

From evidence to actions, lesson learned:

• Prisoners helped by overall advances in HIV treatment. AIDS-related deaths in state prisons decreased 82% from 1995 to 2004.

• Up to 67% of HIV+ prisoners first received ART while in prison.• AIDS-related deaths in prisons in countries in which ART is

available in prisons decreased dramatically (CDC, 1999; Mackenzie et al., 1999; Maruschak, 2001; Babudieri et al., 2005)

HIV in prisons and jail. Factsheet 615Evidence for Action Technical Papers: Interventions to address HIV in prisons: HIV care, treatment and support,

World Health Organization, UNODC, UNAIDS / Geneva, 2007

• Prison populations treated with antiretroviral therapy report the highest treatment successes of any populations ever studied:– Supervised access to care– DOTS equivalent– Readily accessible care (in the same building)– Prison populations often easy to access– Targeted groups: Having some of the highest rates of HIV,

TB infection

From evidence to actions, lesson learned:

HIV in prisons and jail. Factsheet 615Evidence for Action Technical Papers: Interventions to address HIV in prisons: HIV care, treatment and support,

World Health Organization, UNODC, UNAIDS / Geneva, 2007

Lesson learned1. Prison authorities should ensure that prisoners receive care, support and

treatment equivalent to that available to people living with HIV in the community, including ART

2. Ensure ART available in the prison’s system

3. Ensure continuity of care, including ART, from the community to the prison and back to the community, as well as within the prison system

4. Enable Opioid Substitution Therapy (OST) available in prison system so that people can access OST and ART without interruption

5. HIV testing and counseling should be voluntary, easily accessible to prisoners upon entry and during imprisonment, confidential, closely linked to access to care, treatment, and support for those testing positive, and be part of a comprehensive HIV program that includes access to prevention measures.

Evidence for action technical paper: Intervention to address HIV in prisons HIV care, treatment and support, UN 2007

4. Recommendations

Recommendation - System strengthening

• Develop inter-ministerial circular on intersectorial collaboration and support of prisons, PACs and OPCs

• Establish referral system (detailed in the inter-ministerial circular)• Prison HCWs attend regular provincial TA provider network

meetings• HCWs from twinned OPC visit prison clinic monthly to review

cases, provide clinical advice, supervise clinical practice• Encourage technical support and counseling provision to the

twinned units via email, phones • Mobile teams to provide service: X-ray, blood collection,

specimens.

Recommendation - Technical Assistance (TA)

• PACs play key roles in managing and coordinating TA need and provision to prisons

• Training health staff to be able to manage common HIV related diseases

• Hand-on practice at twinned or nearest OPC/TB units• Task shifting

– Maximize wide range efforts peers, volunteers, inmates– Strong linkage, twinned with nearest provincial/district OPCs and TB

units

Recommendation - Patient - Centered care approach

• Peer and volunteer support models• Enhance support activities in prisons• Mobilize support from family members/ spouse of inmates• Follow up upon release: Active discharge planning to prepare

3 months before discharge– Education package– Referral package– Active follow-up / contact after release– Mobilize support from social entities: women’s union, youth union…– Mobilize family support when re-engaging community

( accomodation, job placement, HIV/TB treatment adherence, prevention with positive…)

Key points

• Good prison health is good public health. Prisons are key in management of HIV

• Basic principles and goals of HIV therapy are the same inside or outside of a correctional system

• Collaborative, inclusive, and inter-sectoral cooperation and action required for management HIV in prison

• Suggestion of linked services HIV care and treatment in community and prisons: – TB/HIV depts and OPCs to engage with prison health depts on HTC,

treatment and care for prisoners – Support prisoners upon release to re-engage their community

maintain good treatment outcomes and on-going preventive measures