‘A Trifecta of Bad Outcomes’

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Photo by CorrectionalAssociation via Flickr

Of the 1,700 inmates getting HIV medical treatment at the Dallas County Jail between 2011 and 2013, just 30 percent showed up for a medical check-up within 90 days after they were released back into the community.

That was a key—and worrying—finding of a five-year, multi-city pilot project aimed at keeping former inmates on anti-retroviral drugs. Those drugs are essential to suppressing the virus and, thereby, the risks of formerly incarcerated persons getting sicker or infecting others.

“That 30 percent is a really low number,” said Dr. Ank Nijhawan, a physician treating HIV patients at that Texas jail.

As a kind of comparison, the federal Centers for Disease Control and Prevention found that 84 percent of all persons reported to have HIV in 32 states and the District of Columbia had gotten care within three months of their diagnosis and 75.5 percent had gotten care within 30 days. That’s based on yearly data submitted to the CDC by December 2015.

The precise reasons that the other 70 percent of Dallas County’s former inmates did not seek care outside of jail hasn’t been determined, though the varied difficulties of their personal lives are likely factors, said Dallas County’s Nijhawan, a lead researcher on the pilot project.

The Center for Prisoner Health and Human Rights at Brown University’s Alpert Medical School and Miriam Hospital, an Alpert partner, launched the study. Among its core goals is helping to create a reliable, national standard for calculating how many inmates have HIV and for tracing their path through the health care system, post-prison and -jail.

The biggest obstacle to gaining an accurate count is this: Reporting standards vary by state and, sometimes, from municipality to municipality. In some cases, even laws protecting the confidentiality of a person’s medical history, including and what they choose to disclose about it, have proven to be barriers, researchers said.

Although the pilot project ended in late 2015, researchers are still analyzing HIV data and other information collected from correctional facilities in Rhode Island, North Carolina, Texas and Massachusetts that were study sites; and they have launched additional studies based on their initial findings.

The CDC has estimated that one in seven people living with HIV/AIDS—not the death sentence it used to be, but still, a chronic illness that can be costly to treat—passes through a U.S. jail or prison.

The end-game goal of that five-year study, whose findings were published earlier this year in AIDS Patient Care and STDs journal, is to help correctional health care and community health care workers determine which former inmates discontinue their HIV care after returning to their home communities; and to identify and implementservices that can help them maintain their health regimen.

“Without a continuum of care, there will be serious ramifications downstream,” said Michael Costa, a researcher with ABT Associates in Cambridge, Mass. and co-author of the journal article on the pilot project’s findings.

What’s clear already is that drug addiction, mental illness, lack of housing and unemployment are among the issues preventing some formerly incarcerated persons from continuing their HIV care outside of prisons and jails, researchers said.

‘Trifecta of Bad Outcomes’

“This is a critical issue on a number of fronts,” Costa added. “Somebody who doesn’t take their meds is going to get sick. And as a financial issue, a societal issue, it is much more expensive to re-stabilize people who didn’t maintain treatment than to keep them in treatment to begin with.

“At the public health level, you are raising the viral load for entire communities and raising the likelihood that more cases of HIV will be created. There’s this trifecta of bad outcomes.”

The Dallas jail’s Nijhawan added: “What we want to do is determine predictors of who does well and who doesn’t do well in treatment after they’re released.

“How can we identify those people early on and make sure they get the services they need? We need more dedicated resources, peer navigators, patient navigators … ”

She plans to apply for grants to create an infrastructure designed to keep formerly incarcerated HIV patients in medical care.

Dallas County’s jail and its county-run hospital, Parkland Memorial—where most former inmates get their HIV treatment—are in close proximity to each other. The hospital will play a key role in a proposed system to link HIV patients with health care and counseling services in areas ranging from substance abuse and mental health to housing and employment.

“But we’re still fleshing all of this out,” said Nijhawan, adding that the county jail currently has one HIV caseworker. “Whatever system we come up with is a long ways off.”

For now, the researchers said they are trying to raise awareness of the fall-off in HIV care post-release from detention—and to persuade those with HIV of the benefits of continuing HIV care.

“Incarceration is a time of crisis but it’s a unique time to talk about people’s health and behavioral change,” Nijhawan said. “Not that change always happens, but we do have this unique opportunity to … make them realize that when they’re on medication, they feel better.”

Clinicians and Providers Need Help, Too

An additional focus is on the clinicians and others providing HIV health care and other support services, said Dr. Brian Montague, also a co-author of the journal article and a professor of medicine at Brown University.

“Our intent in the study was to help care-providers set up the frameworks so you could assess, locally and nationally, what is your success in getting people into care,” Montague said. “The interventions must be local because this high-risk population varies from one state to another … services vary from one state to another.

“The hope is that people will take a good, hard look at the gaps in their particular area an figure out what can be done with the resources they have.”

The researchers are also hoping to show that more money should be earmarked to meet the medical and the day-to-day needs of those with HIV who are returning home from prisons and jails.

“The next challenge is to persuade people that this is feasible and doable and important,” said Montague, who treats inmates and former inmates with HIV.

“When you think of all the good stories you’ve heard about HIV over the recent years, they’re not about HIV in the post-release population. And that’s part of a cultural bias against talking about things we can do to help people who’ve been incarcerated re-enter society.”

Katti Gray is a contributing editor of The Crime Report. She welcomes readers’ comments.



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