A national, five-year study of care for
inmates with HIV brought strangers together, produced policy change in
the Delaware Department of Correction and documented the importance of
good communication and coordinated care for those who return to the
community. But many challenges remain in preventing, detecting and
treating HIV in offender populations.
Christy Visher, director of the University of Delaware's Center for Drug and Health Studies,
and her research team Steven Martin, associate director, Daniel
O'Connell, scientist, and several graduate students from the Department of Sociology and Criminal Justice collaborated with eight other research centers on the study, which was supported by the National Institute on Drug Abuse.
Results of that work and recommendations from work with service
providers in Delaware's correctional system and community treatment
centers have been published in a series of reports, including a Delaware case study in the April issue of The Journal of Correctional Health Care.
Researchers in these studies are looking for ways to get effective
HIV programs and interventions out of the laboratory of controlled
studies and into real-world practice. That kind of systemic change is
often difficult, especially in a high-turnover system where training
time is limited and other demands press in.
The stakes are high, though, and researchers agree that critical gaps
in care and treatment exist, especially when inmates are released from
custody.
Improving HIV services and treatment for inmates is considered a
significant public health concern. Inmates are considered at high risk
for HIV, the virus that causes AIDS, and its prevalence among inmates is
more than twice that of the general population.
Poor or inconsistent follow-up after release can mean disastrous
consequences. Researchers in these studies were testing ways to sustain
prevention efforts, testing and treatment for those transitioning into
the community.
According to figures from the Bureau of Justice Statistics (BJS),
about 1 percent of the nation's 2.2 million inmates had HIV/AIDS in
2012, the most recent figures available. Testing requirements and
treatment vary from state to state, but a BJS report published in
February found that many with HIV get treatment with anti-retroviral
drugs while they are incarcerated about 84 percent in state and
federal prisons, about 66 percent in local jails.
But those drugs must be used consistently and must be continued after
release. If the patient has no further treatment or fails to take the
medication, "they not only get sicker but the drugs can stop working,"
Visher said.
Delaware usually has between 81-90 inmates with HIV, said Jim Welch, chief of DOC's Bureau of Correctional Healthcare Services.
The medication averages about $2,600 per month per inmate, he said.
In December, the total cost of HIV medication came to $221,718.
Ensuring those medications are having meaningful impact and are not
just discontinued upon release is an important part of the inmate's
health and an important part of using resources wisely.
Visher's research team focused on treatment protocols, especially on
establishing a "change team" that included corrections employees and
community clinic employees. Those working in the institutional setting
met with those working in the community.
As a result, efficiencies were identified, better understanding
emerged of the challenges faced on both sides of the fence, and
recommendations were developed to improve services and care.
The community treatment participants came from Christiana Care Health
System's HIV Wellness clinic in Wilmington, which has about 900 clients
on a regular basis, Visher said.
Those meetings were enlightening to both sides, Visher said, but she
does not know if the connections and changes they produced are
sustainable. When key people are promoted or transferred or contracts
change, and new staff members are not up to speed on the importance of
the follow-up, information can be lost.
"We've had a couple different contractors," Welch said, "and every
time we have a new contractor there are a lot of people coming in and
out of the system. Sometimes it's difficult to make sure all the
infectious control nurses are up to speed on what happens."
The Christiana Care community clinics around the state are more
consistently staffed, he said, and that partnership has been solid for
25 years.
"The challenges there are the same as many other states have how do you make sure people show up?" he said.
Some recent changes were written into DOC policy and now appear on
forms and other procedural documents, making it much more likely that
those changes will survive personnel changes, said Arlene Bincsik,
director of the clinic for Christiana Care.
The relay of information is a critical factor in caring for this population, she said.
"Delaware's HIV epidemic has had a tremendous impact on patients who
are traditionally medically underserved," she said. "Seventy percent are
minorities, many have a high degree of health illiteracy, mental health
problems, substance abuse problems, and consequently have contact with
core institutions in our state."
When information is inadequate, it can affect care in significant ways.
Historically, for example, there has been no mandatory HIV testing
for those entering the corrections system. If an inmate doesn't alert
officials, the health care team won't know that person has AIDS.
As a result of the "change team" discussions, a question now has been
added to the intake questionnaire, asking the new inmate if he or she
wanted to be tested for HIV. Testing has increased as a result, nurses
say, and that leads to more effective care and greater continuity of
treatment.
"The second part of that process is sharing information with the
patient or inmates permission so that the provider in the correctional
setting knows what treatment they are on, what is working and what
isnt," Bincsik said. "If they are being released, information has to
flow both ways. I think this part facilitating the information is
what was really significant. We had tried to implement improvements with
the Department of Corrections but nothing ever stuck. We feel that the
involvement of the University of Delaware and the formalized process
helped."
DOC nurses and staff were supportive of the efforts and the goals behind them, and that approach makes this work better, too.
"When things work properly, the continuity is extremely tight," said
Karen Swanson, clinical nursing coordinator for the Christiana clinic.
"The patients do not miss medications if were aware of what medicines
they were on. It really does work and it has improved the continuity of
patients' care."
The method used by Visher's team recruiting change team members
from both service areas was productive in this case, all sides said.
But will that catch on? Will it survive other pressures and changes within the criminal justice and community health systems?
"The research enterprise helped activate this," Visher said, "but can
this be done without research? It takes a very strong administrator to
say, 'I've read about this. This is the problem and this is how we're
going to solve it."
Vish
er joined the University of Delaware faculty in 2008 after
working as a senior scientist for the U.S. Department of Justice and a
senior associate with The Urban Institute in Washington, D.C. Her
research has covered many aspects of criminal justice and substance
abuse.
