5 VN is the second highest HIV prevalence in prison Facts and figuresVN is the second highest HIV prevalence in prisonSource: HIV and AIDS in places of detention (WHO 2008) – những con số biết nóiSource: HIV and AIDS in places of detention (WHO 2008) – những con số biết nói
6 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 populationHIV PrevalenceAll Prisoners (State and Federal)Prevalence (%)Slide #13: US HIV Data: Prisons and General PopulationIn 2004, the HIV prevalence among the prison population (state and federal) was 4 to 5 times that of the general population. At year end 2004, 1.8% of inmates were HIV positive (n=23,046; estimated).1Males: 1.7% (n=20,668; reported).Females: 2.4% (n=2084; reported)ReferenceMaruschak LM. HIV in prisons, Bur Justice Stat Bull. November Available at:General PopulationMaruschak LM. Bur Justice Stat Bull. November 2006.Available at:Year
7 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 prisonOther setting32%Slide #11: Why Are Correctional Institutions Important Targets for Intervention?Data from correctional institutions in Connecticut reveal that HIV-infected persons are frequently diagnosed and initiate antiretroviral therapy in prison. For many of these patients, the correctional system offers the first opportunity to obtain access to treatment.Because there are a large number of HIV-infected persons in prisons, this makes prisons important sites for introducing comprehensive HIV care.Data shown on this pie chart are from a study by Mostashari et al based on a cross-sectional interview study conducted at the women’s correctional facility in Niantic, Connecticut.1 During the time of the study, the facility had an average daily census of 660 women, approximately 15% of whom were HIV-positive. Of the HIV-positive inmates, 36% were African-American, 29% were Latina, and 35% were white. The mean age of this group was 34 years. Approximately 90% of these inmates reported that injecting drug use was their risk factor for HIV. A total of 102 of 120 women who were asked consented to interviews. Approximately two-thirds of women received their first offer of antiretroviral therapy in prison. A total of 68% accepted the first offer of antiretroviral therapy.References1. Mostashari F, Riley E, Selwyn PA, Altice FL. Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. JAIDS. 1998;18:Prison68%Mostashari F, et al. JAIDS. 1998;18:
8 Co-morbidity Conditions in the Incarcerated Population Mental illnessUp to 50% have axis 1 or 2 mental disordersSubstance abuse- As many as 75% have alcohol and/or other substance abuse disordersTuberculosis- 40% of Americans intimate with active tuberculosisSTDsHepatitis, especially HCV1.3 to 1.4 million inmates are HCV+Prevalence of HCV in inmates 10x that of US populationIncarcerated women have a higher rate of HCV than incarcerated menSlide #8: Comorbid Conditions in the Incarcerated PopulationHIV-infected inmates frequently manifest comorbid conditions, including mental illness, substance abuse, tuberculosis, sexually transmitted diseases (STDs), and hepatitis -- particularly hepatitis C virus (HCV). In fact, the prevalence of HCV in correctional institutions is 10 times higher than that in the general US population, with a higher rate of infection among women than men.Treatment of HIV alone is not likely to prove effective if these comorbidities are not also addressed. Thus, treatment of HIV and HCV among inmates will often require substance abuse treatment and psychiatric care.References1. DeGroot A. HCV: the correctional conundrum. HEPP News. April 2001.2. Baillargeon J, Wu H, Kelley MJ, Grady J, Linthicum L, Dunn K. Hepatitis C seroprevalence among newly incarcerated inmates in the Texas correctional system. Public Health. 2003;117:43-48.DeGroot A. HEPP News. April 2001; Baillargeon J, et al. Public Health. 2003;117:43-48.
9 HIV in prison setting - the fact: The rates of HIV infection in prisons are 5-7 times higher than those in the general populationUp to ¼ the HIV-positive population of a country pass through prisonsHIV 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 communitySource: 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 615Source: 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
10 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 careSome facilities have no health care provider who know about HIV carePrison conditions contribute to the spread of HIV also influence HIV treatmentHIV in prisons and jails. Fact Sheet Number 615.HIV and AIDS in places of detention (WHO 2008)HIV/AIDS and co-morbidities hepatitis, tuberculosis (TB) and sexually-transmitted infections(STIs) are significant health threats to prisoners, prison staff and their familiesPrison conditions contribute to the spread of HIV (lack space, natural light and fresh air, drinking water and nutrition, poor sanitation) , also influence HIV treatmentHealth services in prison are substandard and under-funded, lack of HIV preventive services, isolated from general health system hamper quality and continuum of carePrisons 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 enormous opportunities to provide treatment, care and supportPOLICY BRIEF: ANTIRETROVIRAL THERAPY AND INJECTING DRUG USERS, WHO, UNAIDS 2005HIV in prisons and jails. Fact Sheet Number 615.HIV and AIDS in places of detention (WHO 2008)
11 Factors assosiated with HIV prevalence in prison Overcrowding:Prisons are overcrowded in 111 countries;Prisons in 39 countries housing 1.5 to 3 times capacityViolence, self harmHigher prevalence of drug use, HIV, hepatitis B and C, TB, mental illnesses than in society outsideVulnerable groups/behaviour:Hierarchical homosexual relationsOther forms of sexual violence e.g. gang rapeTattooingDrug use, including injecting drug use (IDU)
13 Challenges to HIV Care and treatment in Prison Lack of HIV specialists, integrated delivery systems, community standard practicesRemote locationsContinuity of careMistrust and stigmaLanguage/cultural barriersRestricted formulariesConfidentiality/privacySlide #13: Challenges to HIV Care in CorrectionsThe correctional system poses several challenges to HIV care.In some areas, it may be difficult to access specialty care, especially for correctional facilities that are located in remote rural areas. In some places, telemedicine programs have been used to overcome this barrier.Although treatment may be successful during the term of incarceration, ensuring continuity of care postrelease may be more difficult.Initiating HIV treatment often requires confronting inmate mistrust of the healthcare system and overcoming the negative perceptions inmates have regarding antiretroviral therapy. Language and cultural barriers may also present an impediment to treatment. A lack of effective patient education materials in some facilities may further complicate the issue. In addition, inmates may fear that initiating antiretroviral therapy may inadvertently disclose to others that they are HIV positive.In addition, formularies in some correctional facilities may restrict access to certain antiretroviral agents limiting drug choice. Pharmacy dispensation problems or unexpected transfers of inmates may sometimes lead to unintended treatment interruptions thereby increasing the risk that drug resistance might develop.
14 Factors influence HIV care and treatment in prison and jail Prior treatment historyCurrent viral load and CD4 levelsResistance to medicationsOther health issues, such as injectionDrug use mental healthProblems, liver disease, and diabetesPatient preferencesLength of prison termMedication timing relative to inmate activities, food requirements, and refrigeration
15 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 carePrison 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 casesEach staff much deal with the full range of conditions, multi-tasks
16 Health facility in prison in Vietnam Structural factor: close setting, overcrowding, inadequate health careFollow-up after release is very poor with most patients not successfully engaging in care after release:Risk of ARV resistanceRisk of acute Hep B and HIV illness after stopping treatmentPossible 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 referralDOTSSupervision from provincial unit
17 2. Principle of HIV management in prison and jails
18 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.”
19 A WHO guidelines on health in prisons Standards in prison health: the prisoner as a patientPrimary health careCommunicable diseasesHIV infectionTuberculosis controlDrug use and drug services, Substitution treatmentMental healthDental healthSpecial health requirements for female prisonersPromoting health and managing stress among prison staff
20 HIV/AIDS in prison settings … warrants a comprehensive approach Advocacy to mitigate problem of governmental denial & to create favourable legal / policy environmentHIV/AIDS prevention, care and treatment in prison settings equivalent (the same) to outside communityImprovement of general prison conditions byMinimizing overcrowding (e.g. use of alternative measures and diversion programs)Operating secure, safe and orderly prisonsReducing violenceContinuity of care: linkage from prison to community care, comprehensive approach to support when prisoner are released
21 UN Technical guidance on HIV care and support in prison: 15 key interventions Information, education and communicationCondom programs,Prevention of sexual violenceDrug dependence treatment, including opioid substitution therapyNeedle and syringe programsPrevention of transmission through medical or dental servicesPrevention of transmission through tattooing, piercing and other forms of skin penetrationHIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of intervention, UN June 2013
22 UN Technical guidance on HIV care and support in prison: 15 key interventions Post-exposure prophylaxisHIV testing and counselingHIV treatment, care and supportPrevention, diagnosis and treatment of TBPrevention of mother-to-child transmission of HIVPrevention and treatment of sexually transmitted infectionsVaccination, diagnosis and treatment of viral hepatitisProtecting staff from occupational hazardsHIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of intervention, UN June 2013
23 HIV intervention in Prison logic model (proposed) PLWHA Enter PrisonOffer HIV testingPLWHA Declares Status orAccepted HIV TestingHIV TestingPLWHA Released from JailIntensive Case ManagementLinkage and Engagement in HIV Care in CommunityLinkage to Care&Treatment / Discharged PlanningPrimary Care ServiceOther support: Mental Health, Substance Use, Social Support
24 UN Technical guidance on HIV care and support in prison 4 key interventions documented to be effectiveNeedle and syringe program & decontamination strategiesPrevention of sexual transmissionDrug dependence treatmentsHIV care, treatment and supportInterventions to address HIV in prisons , WHO
25 US Prison data: HIV cases and AIDS related deaths decreased by time
26 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.
27 Goals of ART Therapy and Tools to Achieve Maximal and durable suppression of viral load.Restoration or preservation of immunologic function..Reduction of HIV-related morbidity and mortality.Improvement in quality of lifeTOOLSMaximize adherence to the antiretroviral regimen.Rational sequencing of drugs.Reservation of future treatment optionsEarly detection and adequate management of treatment failure.Linkage and Engagement in HIV Care in Community
28 Principles of HIV treatment in prison Prisoners bring information with them (education for patient):HIV medicationsCD4 cells counts and viral loadHIV related illnessSide effectsAdherence: build trust and acceptance of ART, reduce institutional barriers to adherenceAdministration of treatmentWhen to startWhat regimen to useSimplicity, dosing, frequency, side effect profile, drug interactionsARV under direct observation,Modified directly observed therapy (DOT)—significant better resultsPlanning for continuity of care from the outset
29 Antiretroviral Therapy in Prison Settings AdvantagesDisadvantagesStructured settingEqual access to careAvailability of ARTPossible DOTContinuity of careTransfersPotential breach of confidentiality“Unstructured” DOT presence of mental illnessSlide #15: Antiretroviral Therapy in Correctional SettingsThis slide summarizes the advantages and disadvantages of instituting antiretroviral therapy in the correctional setting.The correctional environment provides a structured setting that may be conducive to starting an antiretroviral regimen. In the correctional facility, inmates have equal access to care and follow-up. Antiretroviral treatment may be more readily available to inmates than it would be in the community setting. Incarceration also presents the opportunity for directly observed therapy (DOT), which may enhance adherence.Among the disadvantages associated with antiretroviral therapy in the correctional setting are the numerous opportunities for treatment interruption when inmates are transferred, taken for court appearances, or undergo strip searches. DOT may also be considered a disadvantage in the correctional facility, disclosing to other inmates that the patient is HIV positive. In addition, HIV-positive inmates also frequently manifest mental illness, which complicates the ability to adhere to treatment.
31 From evidence to actions: Thailand Experiences Interventions:Prevention for IDUsHTCHIV care and treatment: OIs, adherence, TB and ART, peer support system, volunteerChallenges:Stigma and discriminationDiscourage from taking medicines in crowded environmentMistrust of prison staffTransfer to other facilitiesPoor social support upon releaseSolutions:Positive attitude of health staffReferral to hospital when neededPlan for continuing treatment before releaseMedication supply for three months before enroll in the community ART program
32 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 stakeholdersCollaboration with health care provider for specialized medical careMoU and collaboration between prison and District hospital, primary health care and TB unit were signedInterventionEssential health care service: TB, HIV, MMT in prisons, Harm reductionTrust building, compliance to HIV prevention and care and peer groupHIV care and treatment: treatment daily under direct supervision
33 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, 2007Effectiveness of interventions to address HIV in prisonsHIV 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
34 From evidence to actions, lesson learned: Prison populations treated with antiretroviral therapy report the highest treatment successes of any populations ever studied:Supervised access to careDOTS equivalentReadily accessible care (in the same building)Prison populations often easy to accessTargeted groups: Having some of the highest rates of HIV, TB infectionHIV 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
35 Lesson learnedPrison authorities should ensure that prisoners receive care, support and treatment equivalent to that available to people living with HIV in the community, including ARTEnsure ART available in the prison’s systemEnsure continuity of care, including ART, from the community to the prison and back to the community, as well as within the prison systemEnable Opioid Substitution Therapy (OST) available in prison system so that people can access OST and ART without interruptionHIV 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 Papers on Effectiveness of Interventions to Address HIV in Prisons.UNODC, INTERVENTIONS TO ADDRESS HIV IN PRISONS – HIV CARE, TREATMENT AND SUPPORTEvidence for action technical paper: Intervention to address HIV in prisons HIV care, treatment and support, UN 2007
37 Recommendation - System strengthening Develop inter-ministerial circular on intersectorial collaboration and support of prisons, PACs and OPCsEstablish referral system (detailed in the inter-ministerial circular)Prison HCWs attend regular provincial TA provider network meetingsHCWs from twinned OPC visit prison clinic monthly to review cases, provide clinical advice, supervise clinical practiceEncourage technical support and counseling provision to the twinned units via , phonesMobile teams to provide service: X-ray, blood collection, specimens.
38 Recommendation - Technical Assistance (TA) PACs play key roles in managing and coordinating TA need and provision to prisonsTraining health staff to be able to manage common HIV related diseasesHand-on practice at twinned or nearest OPC/TB unitsTask shiftingMaximize wide range efforts peers, volunteers, inmatesStrong linkage, twinned with nearest provincial/district OPCs and TB units
39 Recommendation - Patient - Centered care approach Peer and volunteer support modelsEnhance support activities in prisonsMobilize support from family members/ spouse of inmatesFollow up upon release: Active discharge planning to prepare 3 months before dischargeEducation packageReferral packageActive follow-up / contact after releaseMobilize 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…)
40 Key pointsGood prison health is good public health. Prisons are key in management of HIVBasic principles and goals of HIV therapy are the same inside or outside of a correctional systemCollaborative, inclusive, and inter-sectoral cooperation and action required for management HIV in prisonSuggestion 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 prisonersSupport prisoners upon release to re-engage their community maintain good treatment outcomes and on-going preventive measures