Shaping HIV & Correctional Health Care: Research Questions Moving Forward Redonna K. Chandler, Ph.D. Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse July 22, 2012

U.S. imprisons more people per capita than any other country in the world, with 239% growth in 1990s Source: International Centre for Prison Studies,

U.S. Adult Offender Population: Since 2005, combined federal, state, local adult correctional population has been over 7 million. Source: Bureau of Justice Statistics, 2009

Prevalence of Health Screening & Services in Adult CJ % Facilities Providing Service Source: CJ-DATS National Criminal Justice Treatment Practices Survey, NIDA

Westergaard RP et al., J Int AIDS Soc 2012; 15:10. IDU HIV+ Are Much Less Likely to Receive HAART Percentage Of Providers Who Would Defer ART By CD4+ Count and Injection Drug Use Status

Unanswered Research Questions How can HIV services be integrated across the criminal justice system? What is the resistance? What organizational change is needed? What workforce is needed? What implementation strategies work? What will it cost and is it cost-effective? What interventions are needed to reduce stigma associated with drug use, HIV, criminal justice involvement?

HAART as HIV Prevention GD Kirk, et al., 2001, Poster presented at the 18 th Conference on Retroviruses and Opportunistic Infections, Boston MA, February 27-March 3, Montaner et al., Lancet 2008

In a Given Year... About 14% of all people in the US with HIV, & 33% of those with HCV, & 40% of those with TB -- will pass through a correctional facility. In a Given Year... About 14% of all people in the US with HIV, & 33% of those with HCV, & 40% of those with TB -- will pass through a correctional facility. Source: Spaulding et al. (2009); Hammett, Harmon, & Rhodes (2002). AJPH, 92 (11), Treatment planning for drug abusing offenders should include strategies for chronic medical conditions (e.g. HIV/AIDS, Hep B/C, & TB)

ENTRY (Arrest) ADJUDICATION (Trial) PROSECUTION (Court, Pre-Trial Release, Jail) SENTENCING (Fines, Community Supervision, Incarceration) CORRECTIONS (Probation, Jail, Prison) COMMUNITY REENTRY (Probation, Parole, Release) Crime victim Police FBI Crime victim Police FBI Judge Key Players Screening/ Referral Intervention Opportunities Prosecutor Defense Attorney Defendant Jury Judge Jury Probation Officers Correctional Personnel Probation/ Parole Officers Family Community-based providers Diversion Programs Drug Courts Community Treatment TASC Drug Court Terms of Incarceration Release Conditions Drug Treatment Drug treatment Aftercare Housing Employment Mental Health Half-way House TASC N/A Where and How do you Implement STTR in the Criminal Justice System? SeekTestTreatRetain

``` State Receiving Funding NIDA funded PI single award NIDA + NIAID funded PI NIMH funded PI Jail/Prison Location Seek, Test, & Treat: Addressing HIV in the Criminal Justice System Puerto Rico Vietnam

How do we Implement Effective Interventions? What is the cost of STTR? Is it cost-effective? What assessment tools can communities use to determine which evidence-based STTR components to implement? What are the structural/organizational requirements for different evidence-based STTR interventions? What implementation strategies facilitate uptake?

Baillargeon J et al., JAMA 301(8): , Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release Percent 5.4% 17.7% 30% days30 days60 days Only a small percentage of Texas prison inmates receiving ART while incarcerated filled an initial ART prescription within 60 days of release Had prescription filled within:

How do we Promote Patient Sustained Adherence to HAART? What is the role of addiction treatment (including medication) in HAART adherence? What individual barriers impede HAART adherence? What structural and cj system barriers impede HAART adherence? What role can technology play in HAART adherence?

How Do We Leverage Our Scientific Investment? Data Harmonization

Economy, Power, Answer New Questions Increase cross-study comparability, collaboration, scientific yield Multi-site pooling for integrative data analyses Cross-site replication/comparisons Meta analyses Secondary data analyses Maximizes gain while minimizing cost, risk, and time to payoff Promotes construct quantification through integrative data analysis WHY HARMONIZE?

Central core measures are used in every study, forming a pool of common items Specialty core measures may be asked based on specific interests of a sub-set of studies Example: Cost/Cost Effectiveness, Climate/Culture of Jails Regarding HIV Intervention, etc. The Cores STTR Harmonization Constructs Demographics Mental Health CJ StatusDrug Use HIV/IDU Risk HIV/HCV Testing Access to Care Treatment Utilization Adherence Biological Data Measure Level Construct Level VAS, HAART ACTG Questionnaire, ART Pill Count, Chart Review Item Level Core Domains

Thank You Questions