1. Management of HIV in prison
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Management of HIV in prison
Good prison health is good public health

2. Good prison health is good public health:
“Every year, more than 30 million people worldwide enter and leave prison systems and rejoin the communities”

3. Outline HIV in prisons setting
Principle on management of HIV in prison and jails
Lesson learned of HIV care and treatment in prison
Recommendations
Key points

4. HIV in prison setting

5. VN is the second highest HIV prevalence in prison
Facts and figures
VN is the second highest HIV prevalence in prison
Source: HIV and AIDS in places of detention (WHO 2008) – những con số biết nói
Source: 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 population
HIV Prevalence
All Prisoners (State and Federal)
Prevalence (%)
Slide #13: US HIV Data: Prisons and General Population
In 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).1
Males: 1.7% (n=20,668; reported).
Females: 2.4% (n=2084; reported)
Reference
Maruschak LM. HIV in prisons, Bur Justice Stat Bull. November Available at:
General Population
Maruschak 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 prison
HIV-infected persons are frequently diagnosed and initiate antiretroviral therapy in prison
Other setting
32%
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.
References
1. 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:
Prison
68%
Mostashari F, et al. JAIDS. 1998;18:

8. Co-morbidity Conditions in 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 men
Slide #8: Comorbid Conditions in the Incarcerated Population
HIV-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.
References
1. 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 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. 119
HIV in prison and jail. Factsheet 615
Source: HIV and AIDS in places of detention (WHO 2008) HIV in place of detentions: module 5 for prison health staff. P. 119
HIV 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 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
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 families
Prison conditions contribute to the spread of HIV (lack space, natural light and fresh air, drinking water and nutrition, poor sanitation) , also influence HIV treatment
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
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  enormous opportunities to provide treatment, care and support
POLICY BRIEF: ANTIRETROVIRAL THERAPY AND INJECTING DRUG USERS, WHO, UNAIDS 2005
HIV in prisons and jails. Fact Sheet Number
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 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)

12. Source: Dr. Stoever, 2004

13. Challenges to HIV Care and treatment in 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
Slide #13: Challenges to HIV Care in Corrections
The 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 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

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 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

16. 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

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 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

20. 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

21. UN Technical guidance on HIV care and support in prison: 15 key interventions
Information, education and communication
Condom programs,
Prevention of sexual violence
Drug dependence treatment, including opioid substitution therapy
Needle and syringe programs
Prevention of transmission through medical or dental services
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

22. UN Technical guidance on HIV care and support in prison: 15 key interventions
Post-exposure prophylaxis
HIV testing and counseling
HIV treatment, care and support
Prevention, diagnosis and treatment of TB
Prevention of mother-to-child transmission of HIV
Prevention and treatment of sexually transmitted infections
Vaccination, diagnosis and treatment of viral hepatitis
Protecting staff from occupational hazards
HIV 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 Prison
Offer HIV testing
PLWHA Declares Status or
Accepted HIV Testing
HIV Testing
PLWHA Released from Jail
Intensive Case Management
Linkage and Engagement in HIV Care in Community
Linkage to Care&Treatment / Discharged Planning
Primary Care Service
Other support: Mental Health, Substance Use, Social Support

24. UN Technical guidance on HIV care and support in prison
4 key interventions documented to be effective
Needle and syringe program & decontamination strategies
Prevention of sexual transmission
Drug dependence treatments
HIV care, treatment and support
Interventions 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 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

28. 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

29. Antiretroviral Therapy in Prison Settings
Advantages
Disadvantages
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
Slide #15: Antiretroviral Therapy in Correctional Settings
This 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.

30. 3. Lesson learned

31. 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

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 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

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 615
Evidence for Action Technical Papers: Interventions to address HIV in prisons: HIV care, treatment and support, World Health Organization, UNODC, UNAIDS / Geneva, 2007
Effectiveness of interventions to address HIV in prisons
HIV in prisons and jail. Factsheet 615
Evidence 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 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
HIV in prisons and jail. Factsheet 615
Evidence for Action Technical Papers: Interventions to address HIV in prisons: HIV care, treatment and support, World Health Organization, UNODC, UNAIDS / Geneva, 2007

35. Lesson learned
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
Ensure ART available in the prison’s system
Ensure continuity of care, including ART, from the community to the prison and back to the community, as well as within the prison system
Enable Opioid Substitution Therapy (OST) available in prison system so that people can access OST and ART without interruption
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 Papers on Effectiveness of Interventions to Address HIV in Prisons.
UNODC, INTERVENTIONS TO ADDRESS HIV IN PRISONS – HIV CARE, TREATMENT AND SUPPORT
Evidence for action technical paper: Intervention to address HIV in prisons HIV care, treatment and support, UN 2007

36. 4. Recommendations

37. 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 , phones
Mobile 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 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

39. 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…)

40. 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