Identifying the Positive:

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Identifying the Positive

• Evaluating Best Practices for Identifying
  Linking HIV Inmates to Care

Anne Spaulding MD, MPH Principal
Investigator Kevin Ramos, Project Coordinator Ted
Hammett PhD, Abt Assoc.
HRSA/HAB/SPNS Melinda Tinsley, MS Adan Cajina, MS
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Outline

• Introduction
• HIV in jails
• Jail testing programs
• Linkages to HIV care
• Case Study
• Evaluating HIV testing, linkages to care in jail
  and community
• Discussion

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Prior Field Experience

• Anne Spaulding MD MPH
• Medical Director for the Rhode Island Department
  of Corrections 1996-2001
• Associate Statewide Medical Director for Georgia
  Correctional HealthCare/Medical College of
  Georgia 2003-2005
• CDC Medical Officer National Center for HIV, STD
  TB 2001- 2002

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Prior Field Experience (continued)

• Kevin Ramos
• Georgia Department of Juvenile Justice Operations
  Analyst for the Corrections Demonstration Project
  (CDP) 2000-2004
• Program Consultant for Atlanta City Detention
  Center 2000-2002
• Health Service Administrator (HSA) for the Fulton
  County Jail in Atlanta Georgia 1994-2000

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Academic-(Research)-Corrections Collaboration

• Emory and Abt have been collaborating on
  correctional research and evaluation projects for
  10 years
• This seminar will draw upon these collaborations
  and other work
• New HRSA initiative
• CDC-HRSA Corrections Demonstration Project
  (1999-2005)
• The CDC/NIJ Survey of infectious diseases in
  correctional facilities
• Prior field experience

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• Introduction
• Anne Spaulding, MD, MPH

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Population Dynamics in Prisons Versus Jails (2005)

• Annually
• 12 million jail releasees.
• 9 million unique persons.
• 50 of jail inmates are released within 48 hours.

Credit Nicholas Scharff, MD MPH, from whom this
representation was borrowed. Sources See
Harrison and Beck.1,3
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HIV in Corrections

• Rates of HIV among inmates are up to five times
  higher than the total US population.
• HIV testing in jails is often not systematic,
  even for inmates with longer lengths of stay.
• In one state roughly one third of HIV infected
  persons in the state learned of their HIV status
  while passing through jail.

Desai AA, Ltaa ET, Spaulding, et al, AIDS
Education and Prevention 2002
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Awareness of HIV Diagnosis in the US

• 1.1 million Americans are HIV-positive.
• 25 are unaware of their diagnosis.

Aware 825,000
Unaware 275,000

• 63 of new HIV infections are transmitted by
  someone unaware of their status.

Source CDC
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New CDC Recommendations for HIV Testing (2006)

• CDC still advocates voluntary testing.
• Recommendations cover correctional settingsbut
  implementation guidance is forthcoming.
• Major changes include
• HIV testing is recommended for patients in all
  healthcare settings,
• Persons at high risk for infection should be
  tested annually,
• General consent for medical care should assume
  consent for HIV testing and
• The inability to provide prevention counseling
  should not prohibit testing.

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Branson BM, Handsfield HH, Lampe MA, Janssen RS,
Taylor AW, Lyss SB, Clark JE, Centers for Disease
Control and P.
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• HIV Testing in Jail Settings
• Anne Spaulding, MD, MPH

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Spectrum of HIV Testing

• Voluntary
• On requestinmates are tested if they ask
• Targeted (based on risks)inmates are tested if
  they are known to be in certain risk groups or
  have symptoms
• Routineall inmates are tested unless they choose
  to opt out
• Mandatoryall inmates must be tested

Branson BM, Handsfield HH, Lampe MA, Janssen RS,
Taylor AW, Lyss SB, Clark JE, Centers for Disease
Control and P.
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Barriers to Jail HIV Testing

• Inmate-level barriers
• Confidentiality
• Im about to get out
• Competing priorities
• Denial or lack of knowledge of risk
• Public health-level barriers
• Cost of test kits and labor
• Mission related to correctional health care
• Access to jails inmates

• Jail-level barriers
• Cost of test kits and labor
• Staff time needed to conduct test
• Staff qualification to test and diagnose
• Jail mission related to public health
• Obligation to treat HIVs
• Lag time to get results

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Rapid Testing in Jails A match made in heaven
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Credit Robin MacGowan, CDC
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Issues and Challenges HIV Testing Program in
Jail Settings

• Timing of testing
• Program marketing and manner in which testing is
  presented to inmates
• Testing protocols
• HIV counseling associated with testing
• Methods of informing those tested of their
  results
• Confidentiality of results
• Ethics
• Administrative and implementation issues

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Community Linkages to Care

Kevin Ramos, Project Coordinator
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Developing an Effective Linkage Program

• Offer HIV medical care inside the jail
• Establish linkages with community medical
  providers
• Plan for post-release care
• Follow up clients post-release to determine
  whether linkages were made and maintained and to
  make further linkages

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Program Elements

• Face-to-face discharge planning
• Strong emphasis on obtaining accurate information
  on release dates
• Appointments made for releasees with
  community-based service providers
• Hand-holding meet releasees at the gate and
  transport them to their initial critical service
  appointments rather than simply offering
  referrals to providers
• (PAPPimp Avoidance Plan)

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Ideal Program Organization

• Case management to link inmates to existing HIV
  services in the community.
• Wide range of services
• HIV primary care.
• Substance abuse and mental health treatment,
  housing, benefits.

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Typical Program Design

• CBOs work in both the jail and community to link
  inmates to care
• Case Managers split time between jail and
  community
• Case Managers meets with client at least once
  before they are discharged
• Case Managers develop a discharge plan that
  prioritizes inmates needs and make referrals and
  appointments with providers in the community

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Program Design (continued)

• Community Case Managers continue to work with the
  released inmate in the community to follow up on
  the discharge plan or make new referrals

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To Sustain a Program

• Ensure service delivery meets clients needs.
• Seek participation from the community in
  developing and implementing programs.
• Evaluate outcome data
• was the money well spent?

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Benefits of Community Linkage Program

• HIV infected individuals are linked to care
  sooner
• Positive health outcome for HIV infected
  individuals and the community
• Reduce HIV transmission in the community
• HIV risk behavior changes after infection
  diagnosed
• Cost savings and ease of burden on the health
  care system

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Linking to Care is a Collaborative Effort
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Administrative Issues for Linkage Programs

• Having appropriate space in the jail
• Coordinating the new program with existing
  services
• Authorizing community-based organizations, public
  health departments and other agencies to work in
  the facility
• Meeting facility security requirements

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Evaluation Support Center Enhancing Linkages
Kevin Ramos, Project Coordinator
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Definition

• Evaluation involves assessing the strengths and
  weaknesses of programs, policies, personnel,
  products, and organizations to improve their
  effectiveness.
• American Evaluation Association

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HRSAs Initiative on Enhancing Linkages to HIV
Primary Care in Jail Settings

• 10 demonstration sites will assess the
  effectiveness of their selected model
• Providing linkages to HIV primary care services
  for jail releasees
• Integrating services for releasees within the
  communitys HIV continuum of care

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ESC Organizational Chart
Emory
Abt Associates
Anne Spaulding MD MPH Principal Investigator
Theodore Hammett PhD Co-Investigator
Douglass McDonald Project Quality Advisor
Kimberly Arriola PhD, MPH Co-Investigator
Joseph Lipscomb, PhD Co-Investigator
Sofia Kennedy Project Manager
Kevin Ramos, Project Director
Hugh McDonough Web Services
Steve Resch Data Analyst
Anitra Sumbry, GRA
Kevin Mihal Finance Contract Adm
Meetings Evaluations Web Services TA/Site
Visits Reports
Consultants Advisory Board
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Grantee Locations
NY
PA
RI
OH
MA
IL
CT
SC
GA
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Demonstration Sites and Services
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Demonstration Sites (contd)
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Demonstration Sites (contd)
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Demonstration Sites (contd)
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Demonstration Sites (contd)
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HANDOUTCase Study
Anne Spaulding, Principal Investigator Kevin
Ramos, Project Coordinator
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Case Study Analysis

• Problems
• Tenuous relationship with the jail
• May be difficult to implement the program without
  support of both management and line staff.
• Use of outside staff takes burden off jail
• Not involving jail staff may compromise
  sustainability.

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Case Study Analysis cont

• HIV testing
• CTS specialist not qualified to work in jail.
• But
• Many inmates would have missed testing given
  emphasis on testing those still in jail at 48
  hours.
• Many eligible inmates would have been be missed
  given the proposed working hours for the CTS
  specialist.

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Case Study Analysis cont

• In order to know what proportion of inmates are
  tested
• and what proportion of those tested who test
  positive
• need administrative data from the jail on the
  number of inmates passing through the jail.

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Case Study Analysis cont

• Case management
• Inclusion criteria are pretty stringent many
  inmates will not remain for 3 or more weeks, and
  short-termers may comprise those who need
  linkage services most.
• Program may have very few clients and an even
  smaller number who complete F/U.

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Evaluating HIV Testing in Jails
Anne Spaulding, MD, MPH
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ESC Discussion

• Expected challenges
• Generalizable knowledge
• Projected outcomes

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Overall Research Objectives

• To identify
• the most effective and replicable intervention
• the intervention that reaches largest numbers
• the intervention that provides best services
• To identify tiered interventions that offers
  different types and intensities of services to
  different groups of inmates
• To determine the least you can do and still have
  success

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Aggregate-Level Data Elements

• Number of inmates tested inside the jail
• Number of rapid (based on confirmatory test) and
  traditional positive tests
• Number of newly diagnosed inmates.
• Inmates generally need a documented positive HIV
  test to get treatment in jail, so much testing is
  done on known positives

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Aggregate-Level Data Elements Continued

• Number of inmates received results (negative and
  positive)
• Demographics and criminal justice data (e.g.,
  recidivism)

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Importance of Denominators

• Determine
• Persons Served
  
• Total of Potential
  People
• Who Could Be Served

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Denominators For HIV Testing Data

• Number of jail admissions
• in a given period
• jail admissions (different inmates) in a given
  period
• inmates still in jail at time of test
• If testing does not occur at intake
• Number of inmates
• offered HIV testing
• who accept HIV testing
• tested who already know they are HIV infected

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Sources of HIV Testing Data and Processes for
Getting Them

• Program data from staff delivering the
  intervention
• Health data and numbers served from jail medical
  department and electronic medical records.
• Jail administrative data
• Lab data
• Public health departments or CBOs to deliver HIV
  results and provide data

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Strategies For Getting Data

• Electronic data capture
• Make evaluation forms dovetail with other program
  reporting requirements
• Training
• Technical assistance
• Frequent and rapid data processing to aid in
  identifying problems

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Qualitative Evaluation Questions

• Inmate experience
• Why would inmates not want to get tested in jail?
• What would make it easy and appealing to get
  results from a community/public health provider
  post-release?
• Staff experience
• What are the benefits of and challenges to rapid
  testing?
• What are the benefits of and challenges to
  routine and voluntary testing programs?

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Evaluating Linkages to HIV care

• Aggregate and individual-level data elements for
  measuring success in linking HIV-positive inmates
  to care.
• Data sources
• Aggregate instruments
• Individual-level instruments
• Utilization of services
• Face-to-face interviews

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In-Jail Data Elements

• Approached for linkage program
• Accept linkage program
• Agree to be in the evaluation (client-level).
• Baseline interview documenting existing community
  linkages
• Actually served by linkage program (i.e., not
  released)
• Received any discharge planning services

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Post-Release Data Elements

• Released to street
• Attended appointment with program contact post
  release
• Attended linkage services one time
• Maintained linkage to services over follow-up
  period
• Connected to additional services post-release
• Follow-up interview on post-release service
  utilization

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Evaluation and Support Center (ESC)

• The Rollins School of Public Health of Emory
  University and Abt Associates Inc. a research
  firm in Cambridgewill serve as the Evaluation
  and Support Center (ESC)
• Serve as a source for scientific, jail and public
  health program policy, program implementation,
  and clinical technical assistance for sites.
• Lead and facilitate the work of demonstration
  sites in developing and refining their
  interventions and local evaluations
• Provide technical assessments, support and
  training, communication, and dissemination
  activities

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Evaluation and Support Center

• Accomplishments to date
• Hosted a meeting of experts to discuss the design
  and evaluation of HIV testing and linkages
  programs in October 2006
• The findings were reported to HRSA and are posted
  on the CHIP portion of the Emory website
• Supported HRSA in development of site RFA
• Publications and presentations

http//www.chip.sph.emory.edu/documents/Consulta
ncyReport_update012907.pdf
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Resources

• HRSA
• https//grants.hrsa.gov/webExternal/SFO.asp?ID083
  9346E-9F9B-4797-8DA4-13093BCBBF32
• Tools for Grantees
• http//hab.hrsa.gov/tools/spnsgrantees.htm
• CDC Public Health and Criminal Justice
• http//www.cdc.gov/nchstp/od/cccwg/default.htm
• Program for the health of incarcerated persons
• http//www.chip.sph.emory.edu/JailESC/

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To Continue this Discussion

• Join our listserv
• Listserv_at_listserv.emory.edu
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  First Name Last Name

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Contact Information

• Anne Spaulding MD MPH Aspauld_at_sph.emory.edu
• 404-727-3369
• Kevin Ramos
• Klramos_at_sph.emory.edu
• 404-727-3288