1. HIV and STD Programs in Jail Hampden County, Massachusetts T Lincoln March 2002

2. Corrections Statistics- USA 2 million incarcerated (world ~ 8 million) Including probation and parole, 6 million persons involved with corrections- 3% of all U.S. Adults 13% of African-American men cannot vote due to this “Invisible population” 25% of some neighborhoods Incarceration rate has more than tripled since 1980 “34th state”

3. Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Hammet T, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999

4. HIV DATA 2000 Massachusetts –annual AIDS rate = 18.9 per 100,000 –31% IDU, 27% female Metropolitan Springfield (population ½ million) –annual AIDS rate = 24.2 per 100,000 –44% IDU, 37% female Hampden County Correctional Center –5.5% of men and 8.7% of women HIV positive on intake (1996) –usually ~75 known HIV patients at jail

6. Community Integrated Correctional Health Care The Hampden County Public Health Model

7. EForPk 16 Acres LibPine Pt E Spf BosRd ForPk IndUppH Met OldH McK Mem Bay Bri 6Cor S.End Springfield Community Partnership and Prevention Alliance, 1995

8. Public Health Model- Current Structure 4 jail health teams integrated with 4 community (neighborhood) health centers Patients assigned to health team by zip code or prior association with community health center Dually based team members in 4 health centers and jail Physicians and HIV case managers primarily community health center based Nurse practitioners, primary nurses primarily jail based Community corrections (probation/parole/DRC) component in development

9. Public Health Model for Corrections Education Prevention Early detection Treatment Continuity of care Reservoir of Illness Proactive v. Reactive Sentinel function Public Health Department Community-integrated model

10. A Vertically and Horizontally Integrated Model Comprehensive, Holistic Services Continuity of Care from Correctional Facility to Community

11. STD Nurse Visits By Year ( Not Screening) Men HCCC

12. Model for Correctional Health Care: Evaluation Support: CDC, Soros Foundation, NIJ Various facets: Chronic conditions (medical and mental), prevention (HIV, STD, TB, viral hepatitis), HIV treatment, continuity of care Cost: $9-10/inmate-day, 10% of $44 million budget. ACA average cost prisons 10%. MA 12%. Economic analysis: A-team –HIV prevention- voluntary counseling & testing –Urine chlamydia screening and partner services

13. Hampden County Correctional Center 1800 inmates- 90% men, 10% women Pretrial and sentenced % released:20%36%67% at:3days2wks3mo 70% street drugs- 80% past month, 11% men & 25% women shared needles 46% in jail in past year

14. HCCC intake population- self-report 2Q1999 Sexual Behavior: –49% sex within a year and never use condom, –70% drink/use drugs during sex –11% report prior chlamydia HIV/AIDS: –69% ever tested for HIV –83% feel low/no chance of getting HIV

15. HCCC program flow Intake health screen- day 1 –Nurse visit- Brief history & exam includes HIV history, mental health screen –RPR, CBC, ALT, PPD planted –UA (with leukocyte esterase), pregnancy test, since 2/99 urine LCx for chlamydia & brief STD questions –Gonorrhea- Gen-Probe if symptoms, risk, LET+ Intake Unit- day 1-3/4 –Education and orientation- includes HIV/hepatitis. Video, instructor led, peer education.

16. HCCC program flow History and Physical- day 3/4 –Nurse practitioner –Documentation of HIV test acceptance/refusal HIV voluntary counseling and testing –Referral from: Prior medical (priority fast-tracked) and education events Ongoing education programs Care of other medical concerns Patient request

17. HCCC program flow HIV voluntary counseling and testing (cont’d) – MA Dept Public Health lab and VCT questionnaire STD –Treatment –Partner elicitation and outreach through MA DPH STD Disease Intervention Specialist includes partners of men with chlamydia Continuity of care –HIV: Case management is key. 90% show rate at follow-up after release

18. Syphilis- Hampden County

19. Key Points Jail is community. Almost everyone returns. Temporarily displaced. At risk. Public health opportunity. Triad of corrections, community and public health. Program description- set the stage Need for economic analysis to inform resource allocation