Jails as an Opportunity to Increase Engagement in HIV Care: Findings from an Observational Cross-Sectional Study Ann K. Avery, Rachel W. Ciomcia, Thomas Lincoln, Maureen Desbrais, Alison O. Jordan, Aadia I. Rana & Rhoderick Machekano AIDS and Behavior ISSN 1090-7165 AIDS Behav DOI 10.1007/s10461-012-0320-0
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Author's personal copy AIDS Behav DOI 10.1007/s10461-012-0320-0
ORIGINAL PAPER
Jails as an Opportunity to Increase Engagement in HIV Care: Findings from an Observational Cross-Sectional Study Ann K. Avery • Rachel W. Ciomcia • Thomas Lincoln • Maureen Desbrais • Alison O. Jordan • Aadia I. Rana • Rhoderick Machekano
Ó Springer Science+Business Media New York 2012
Abstract Linkage, engagement, retention and adherence to care are necessary steps along the HIV care continuum. Progression through these steps is essential for control of the disease and interruption of transmission. Identifying and re-engaging previously diagnosed but out-of-care patients is a priority to achieve the goals of the National HIV/AIDS strategy. Participants in the EnhanceLink cohort who were previously diagnosed HIV? (n = 1,203) were classified as not-linked to of care and non-adherent to medication prior to incarceration by self report. Results based on multivariate models indicate that recent homelessness as well as high degrees of substance abuse
correlated with those classified as not-linked to care and non-adherent to medications while having insurance was associated with being linked to care and adherent to care. The majority of detainees reported being linked to care but not currently adherent to care confirming that jails are an important site for re-engaging HIV? individuals. Keywords HIV Jail Engagement to care Adherence to care
Introduction A. K. Avery (&) MetroHealth Medical Center, 2500 MetroHealth Dr. C-2001, Cleveland, OH 44109, USA e-mail:
[email protected] A. K. Avery Case Western Reserve University School of Medicine, Cleveland, OH, USA R. W. Ciomcia Care Alliance Health Center, Cleveland, OH, USA T. Lincoln M. Desbrais Baystate Medical Center, Springfield, MA, USA A. O. Jordan New York City Department of Health and Mental Hygiene, New York City, NY, USA A. I. Rana Alpert Medical School of Brown University, Providence, RI, USA R. Machekano Elisabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
While overall morbidity and mortality for HIV infected individuals in the United States have markedly improved since the introduction of potent antiretroviral therapy, these successes are limited to those who remain in regular medical care. Recent analyses show only 50 % of individuals previously diagnosed with HIV in the United States are fully engaged in care and only 19–28 % of all people living with HIV and AIDS (PLWHA) are adherent to HAART with undetectable viral loads [1, 2]. The public health ramifications of these data are clear as engagement and retention in care are a crucial component of the National Institutes of Health ‘‘seek, test, and treat’’ strategy in order to impact the stagnant annual incidence of over 56,000 new HIV infections in the United States [3]. Given the dual benefits of treatment improving one’s individual health [4] as well as decreasing the risk of transmission to others in the community [5], there is an urgent need to identify interventions to re-engage out-of-care PLWHA [2, 6]. Strategies to improve retention in care rely on the individual being locatable and willing to engage. For many patients who are out of care, substance use, untreated
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mental illness or unmet basic needs prevent them from being reached by traditional outreach efforts. Venue based outreach, including in jails, has been used for HIV prevention activities including education and testing. With 17 % of PLWHA spending time in a correctional facility [7] and the frequency that jail detainees experience conditions that generally affect engagement in medical care, such as lack of resources, competing basic needs, and mental health and/or substance abuse co-morbidities [6–8], jails may offer unique opportunities to link or re-engage those who are not actively in care. Many prisons (which house sentenced criminals) provide discharge planning services which may include a medication supply and appointments post release for HIV? inmates. In contrast, 75 % of jail detainees return directly to the community upon release rather than being sent to prison. Discharge planning is rare among jails due to their chaotic and unpredictable nature. For persons who remain in jail more than a day or two, maintaining or resuming their HIV care is essential to their health and provision of medical services is required by law. Time and personnel restrictions as well as legal barriers such as HIPAA frequently limit or delay external confirmation for jail medical staff and as such, most personal health information is gathered by self report, including current medications, recent lab results and engagement in care. Despite the limitations in verified data or resources, correctional facilities should offer opportunities for improving one’s health, well being and behavior including identification and re-engagement of those who are out of care and strengthen ties to those who are marginally engaged or at high risk of falling out of care. Jails also offer the opportunity to address risk behaviors for HIV and treat co-morbid diseases associated with HIV and criminal activities, including addiction and untreated mental illness [9]. Providing consistent treatment for addiction and mental illness is the desired standard of care, although data that providing medication for mental illness reduces recidivism are lacking [10, 11]. When common structural barriers that reduce access to medical care are alleviated, individuals that are usually not interested or willing to address their health issues theoretically may be more receptive to services such as disease education, medication evaluation and adherence counseling. Ignoring HIV issues in jail does not lower the cost to society, but rather transfers it from one public entity to another [12], as most jail detainees will return to the community from which they are arrested. As part of a multi-site project evaluating unique interventions designed to improve linkage and engagement to care for HIV-positive jail detainees upon release from incarceration, we sought to quantify the medical and social needs of PLWHA who enter jail focusing on those who report not being linked to care or not being adherent to antiretroviral medication (ART).
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Methods EnhanceLink is a federally funded, 10-site demonstration project that is implementing and evaluating diverse models of HIV testing and linkage in jail settings. Demonstration sites are located in Atlanta, GA; Chester, PA; Chicago, IL; Cleveland, OH; Columbia, SC; New Haven, CT; New York, NY; Philadelphia, PA; Providence, RI; and Springfield, MA and details of interventions have been previously described [8]. The multisite study was approved by the Institutional Review Boards of Emory University and Abt Associates, and individual site programs were reviewed by the responsible IRBs (including special review criteria for prisoners). A Certificate of Confidentiality was obtained for the study. HIV-positive clients were recruited to participate in a voluntary evaluation of their experience in the linkage programs. Other than a mandate that participants be at least 18 years of age, sites varied in criteria for enrollment in the client-level evaluation. This analysis focuses on previously diagnosed HIV-positive clients to assess their engagement in care prior to incarceration (Fig. 1).
Data Collection From January 2008 through March 2011, project staff administered a baseline assessment to enrolled detainees. For the present analysis, clients diagnosed with HIV during this jail stay were excluded (n = 53), as were clients missing the baseline interview (n = 15); one person was both newly diagnosed and missing the baseline form. Of note, 22 clients reported being newly diagnosed on the baseline interview were later noted by jail chart review to have been diagnosed prior to the index incarceration and thus were included. Twelve hundred and three previously diagnosed participants had completed baseline interviews and are described below. Baseline surveys included questions on demographic characteristics, substance use and mental and physical health and were most often completed within the first few days of incarceration. Medication adherence and engagement with an HIV care physician were obtained via self report. Laboratory values were collected from review of the jail chart and included results from prior to incarceration, if available. Newly incarcerated individuals were asked ‘‘During the 30 days before your most recent incarceration, did you have a usual health care provider or place where you get HIV care?’’ Those who answered ‘‘yes’’ were classified as ‘‘linked’’; those not answering ‘‘yes’’ were deemed to be ‘‘not-linked’’. ‘‘Adherent to ART’’ was defined by self report of more than 90 % adherence to HIV treatment in the 7 days prior to incarceration and was limited to those who reported ever taking HIV medications. Severity of drug and alcohol
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1270 enrolled 53 newly diagnosed 15 no Baseline 1 Both 1203 previously diagnosed HIV+ inmates 319 (26.5%) reported not having HIV provider in last 30 days
884 (73.4%) reported having HIV provider in last 30 days
776 (87.8%) reported taking HIV meds (ever)
365 (47%) reported taking > 90 % of HIV meds 7 days prior to incarceration
108 (12.2%) reported never taking HIV meds
152 (19.5%) reported 90% of HIV meds 7 days prior to incarceration
111 (34.8%) reported never taking HIV meds
21 (11.5%) reported taking
