Expanding HIV Testing, Prevention and Treatment in Jail Are we - - PDF document

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Expanding HIV Testing, Prevention and Treatment in Jail

Are we equipped to traverse “the last mile”?

A Asa Clemenzi-Allen, MD, MAS

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About Me

• UCSF
• Internal Medicine Residency
• Fellowship in Infectious Diseases
• Master of Advanced Sciences, Clinical Research
• Director of HIV & Integrated Services,
• Jail Health Services, San Francisco Department of Public Health
• Assistant Clinical Professor (Volunteer), Div HIV, ID and Global Medicine
• Ward 86 Positive-health Onsite-program for Unstably-housed Populations (POP-UP)

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Disclosures

• No Potential Conflicts of Interest to Disclosure

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Clinical Case #1

33 trans-, latinx female, diagnosed with HIV in February, 2018 but remains disconnected from care

• Diagnosis
• HIV testing performed per request of patient within 4 days of intake of first

episode of incarceration

• Initial CD4 402/HIV VL 80k
• Initiated ART within 7 days of diagnosis
• Post-Release Follow-Up
• No outpatient visit since diagnosis
• Ongoing unstable housing and substance use disorder (amphetamine)

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Clinical Case #1

33 trans-, latinx female, diagnosed with HIV in February, 2018 but remains disconnected from care

• Connection to Care
• 2 incarcerations in the last year were only time she had been on ART
• Left substance use treatment program following release from jail
• Motivated to connect to care and remain on ART

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Clinical Case #1

33 trans-, latinx female, diagnosed with HIV in February, 2018 but remains disconnected from care

• What services or strategies are available to HIV optimize outcomes for

this patient?

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Clinical Case #2

38 African American male, born and raised in the Bayview neighborhood with new diagnosis of HIV

• Initially refused testing at intake, but accepted after referral from HIV Testing

Services

• Previously tested negative for HIV 8 months ago while in jail
• Diagnosed and treated for Gonococcal urethritis and late-latent syphilis
• Untreated HCV
• HIV risk
• Amphetamine and heroin use (no IVDU) x3 years which started after divorce
• Sex with women only, but often in the setting of substance use
• Became homeless in the context of divorce and substance use

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Clinical Case #2

38 African American male, born and raised in the Bayview neighborhood with new diagnosis of HIV

• Desires to start ART ”ASAP”
• Contemplative about substance use treatment
• What are the strategies to enhance linkage to prevention services?

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Promoting Linkage to Testing and Care

Pre-Incarceration Disengagement from Care Opportunities for testing and linkage to treatment and prevention services Post-release Engagement in Care

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Discussion Outline

• What are the individual and structural barriers to engagement in HIV

testing, prevention and care?

• What is the current state of HIV testing and treatment in Jails
• What are the strategies to enhance
• Reach of HIV Testing
• Linkage to Prevention Services
• Retention in Care Among People Living with HIV

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Jails v Prisons

• Prison
• Long-term incarceration for people convicted of a crime
• Overseen by state and federal governments
• Jails
• Short-term incarceration for people awaiting charges or convictions
• run by city, counties

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HIV Prevalence In Correctional Settings

• HIV seroprevalence among incarcerated individuals (Beckwith et

al 2010 MMWR)

• Approximately 3 times greater than among the general U.S. population
• Approximately 150,000 people living with HIV in jail or prison
• people living with HIV pass through jail (Spaulding et al 2009

PLOS)

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At-Risk for HIV, Disengagement from Care

Substance Use Disorder Racial/Ethnic Minority Psychiatric Disease Homelessness/ Unstable Housing

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At-Risk for HIV, Disengagement from Care

Substance Use Disorder Racial/Ethnic Minority Psychiatric Disease Homelessness/ Unstable Housing

40% - experience homelessness 2% - percent of total population living with HIV who experience homelessness and incarceration 47% - non-latinx white 56% - history of substance use disorder 32% - under the influence of an illegal drug at the time of arrest Westergaard et al 2013 Curr Opin Infect Dis; Prins et al 2015 Psych Serv 20% with serious mental illness

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Structural Barriers during Incarceration

• Incarceration patterns prevent linkage to appropriate services (Spaulding et al

2010 AJPH)

• 50% - with less than 7-days stay
• 25% - <2 days; 75% < 15 days
• 60% - with one incarceration (general population from 2001 – 2018)
• 17% - with 2 incarcerations
• 11% - 3-4 incarcerations
• Stigma and mistrust of institutions prevent (Westergaard et al 2013 Curr Opin Infect

Dis)

• Disclosure of HIV-risk behaviors
• Disclosure of HIV diagnosis

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Suboptimal Care Engagement

• were engaged in HIV

care prior to incarceration

• Have one visit post-

release

• Achieve virologic

suppression post-release

• of those undergoing

HIV testing had not received prior testing

Nijawan et al 2015 AJPH

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Gaps in HIV Testing in U.S. Jails

• f Jails nationally confirm to best

practice HIV testing policies provide testing services have opt-out testing

Solomon et al 2014 Health Aff

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Gaps in HIV Treatment in U.S. Jails

• ffered ART

provide recommended discharge planning services provide only passive referral

Solomon et al 2014 Health Aff

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Interventions to Address Current Gaps

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• 1. Increase HIV, STD and HCV Screening
• Opt-out testing is feasible and Acceptable to increase HIV testing in jail
• Offered at the time of entry in order to maximize likelihood of acceptance of testing

and timely linkage to appropriate medical care

• Pilot studies demonstrated increase in testing 6-7x in jail settings (Beckwith et

al 2018 AJPH)

• Identify previously undiagnosed people living with HIV
• Identify previously diagnosed who are out of care
• Enhance connection to low-barrier, harm reduction services for those who are HIV

negative, but at increased risk

• Can increase testing for STDs and other communicable diseases (West

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• 2. Addressing Unmet Needs
• Connection to supportive housing within the general population is

associated with

• Lower risk for HIV acquisition (Lee et al 2019 AIDS Behav)
• Improvements in virologic suppression (Zhong et al 2018 CROI)
• Connection to Medical-Assisted Therapy for substance abuse
• Naltrexone for alcohol use disorder improves virologic suppression (Springer et al JAIDS

2018)

• Buprenorphine for opiate use disorder improves virologic suppression (Springer et al

2012 PLOS)

• Connection to medical services for Hepatitis C treatment
• Initiation of treatment in jail is feasible (Akiyama et al 2018 BMC Infect Dis)

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• 3. Pre-Exposure Prophylaxis in Jails
• Feasible setting for implementation, but
• Major obstacles remain
• Patient education (Dauria et al 2018 Adherence Conference)
• Cost and institutional constraints
• Implementation of risk assessment tools for clinicians (Brinkley-Rubinstein et al

2019 Curr HIV/AIDS Report)

• Development and implementation of standardized procedures (ibid)

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• 4. Case Management and Navigation Services
• Peer-led (Cunningham et al 2018 JAMA Int Med)
• Can improve virologic suppression and engagement in care
• Particularly effective among people experiencing homelessness
• Financial Incentives to enhance connection to services (Stitzer et al 2017 Addict Sci Clin Pract)
• Demonstrated to improve connection to navigators among people who inject drugs
• Improves connection to methadone treatment (Sorensen et al 2007 )
• No improvement above navigation alone in virologic suppression (Metsch et al 2016

JAMA)

• No difference in substance use between in group receiving financial incentives
• Strengths-based case management (e.g. Motivational Interviewing)
• Effective in improving retention in care when initiated prior to release (Gordon et al

2018 AIDS Behav)

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• 5. Transition to Low-barrier, Community-

based Care

• Low-barrier, drop-in appointments (e.g. without a scheduled clinic

visit) are a major barrier to attending clinic visits (Dombrowksi et al AIDS Care

2017; Yehia et al BMC Infect Dis 2017)

• Evidence demonstrates feasibility for people living with HIV in people

who are homeless or unstably housed (Dombrowski et al 2019 AIDS Care, Kertesz

et al 2013 AJPH)

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• 6. Approaches to Patient Engagement

Minimal evidence to date, but widely accepted in clinical practice

• Relationship-Centered Care (Beach et al 2012 JGIM)
• Focus on goals and priorities of patient’s in order to promote trusting doctor-

patient relationship

• Trauma-Informed (Bowen et al 2016 AJPH)
• organizational change process centered on principles intended to promote

healing and reduce the risk of retraumatization for vulnerable individuals

• Composed of 6 key component: Safety, Trustworthiness and Transparency,

Collaboration and Peer-Support, Empowerment, Choice, Intersectionality

• May be limited in jail (institutional trauma)

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Clinical Case #1 – Follow-up

33 trans-, latinx female, diagnosed with HIV in February, 2018 but remains disconnected from care

• Which interventions would you prioritize to improve connection to HIV

care?

• A. Case Management
• B. Navigation Services plus Financial Incentives
• C. Navigation Services
• D. Text Messaging

E. All of the above

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Clinical Case #1 – Follow-up

33 trans-, latinx female, diagnosed with HIV in February, 2018 but remains disconnected from care

• Intensive case management to address multiple unmet needs
• Connected patient to transitional housing through a substance use treatment

program

• Navigation
• Patient was accompanied to initial appointments with a navigator and a peer

from her treatment program

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Clinical Case #2 – Follow-up

38 African American male, born and raised in the Bayview neighborhood with new diagnosis of HIV

• Which of following are NOT demonstrable limitations of methods to

enhance navigation services?

• A. Financial incentives are associated with increase substance use
• B. Financial incentives improve connection to navigators, but no impact on

virologic suppression for people living with HIV

• C. Peer-support navigation models are important features of Trauma-

Informed Care models

• D. Both A & C

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Clinical Case #2 – Follow-up

38 African American male, born and raised in the Bayview neighborhood with new diagnosis of HIV

• Financial Incentives
• Attended follow-up drop-in visit at HIVIS office
• Case management
• Ensured medication acquisition and adherence
• Peer support
• Supported her in substance use treatment and medical care

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Is there a roadmap to get there?

Pre-Incarceration Disengagement from Care Opportunities for testing and linkage to treatment and prevention services Engagement in Care and Prevention Services

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Implications for Ending the HIV Epidemic

• Additional funding for program implementation and research may

become available for people who are criminally-justice involved

• HIV & Integrate Services team at Jail Health Services has submitted a

request to fund a multi-component, evidence-based intervention to improve retention in care and connection to HIV prevention services

• Flexible, on-demand navigation services to HIV treatment and prevention

services

• Enhanced with financial incentives, trauma-informed care and
• Coupled with low-barrier, community-based clinical care

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Goals for Program Development and Evaluation

• Using Implementation Sciences framework to guide Community-Based

Participatory Research agenda

• Define HIV incidence in people with recent criminal justice involvement
• What proportion of new HIV infections can be avoided with connection to HIV prevention

services while in jail?

• Quantify the contribution of people with CJI to local HIV transmission
• What will be the community-level impact of HIV treatment in jail on HIV transmission?
• Evaluate patient preferences for HIV treatment and prevention services for CJI

patients

• Can we refine interventions by soliciting patient preferences for HIV treatment and

prevention services?

• Augment coordination data-sharing between DPH departments to provide

real-time metrics of program performance

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Conclusions

• Jail remains an institutional contact for people with elevated risk for HIV

acquisition and disengagement from HIV care

• Well-positioned to institute HIV testing, prevention and treatment outcomes
• Substantial individual-level and structural barriers
• Major gaps in optimal seek, test, treat and retain strategies
• Multiple interventions are available to implement in these institutions to

close these gaps

• “Ending the HIV Epidemic” initiative provides a roadmap for implementing

and evaluating program development to target this key population

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Acknowledgements

• Dr Meg Newman, Diane Havlir and Annie Leutkemeyer
• Fellowship Mentors
• Monica Gandhi
• Elvin Geng
• Katerina Christopoulos
• Compassionate, dedicated service providers extending the reach of

life-saving prevention and treatment services

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Questions/Comments

• Thank You!

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