Introduction

At long last, politicians, public health officials and the lay public are recognizing that the correctional health unit, as Bureau of Prisons Medical Director, Dr. Newton Kendig puts it, lies "at the nexus of public health." (Full speech from the National Conference on Correctional Health Care located on page 4.) Why are our care decisions public health decisions? Simply put: corrections is the setting where our nation's most at-risk persons access organized health care.

The topic of creating links between public health and corrections was the focus of two recent meetings: the HIV/AIDS Behind Bars Pre-conference, organized by the HIV Education / Prison Project at the National Conference on Correctional Health Care on November 5, 1999, and the Integrating Public Health and Corrections Collaborations Conference in Chicago, October 5-7, 1999. Both meetings were well attended by correctional health providers, wardens, sheriffs, and public health officials - more than 100 correctional specialists attended the Ft. Lauderdale pre-conference, filling the conference room to capacity. The Chicago meeting featured an inspirational plenary offering by the Reverend Jesse Jackson, who reminded the audience that we are "all under one big tent," thus decisions about health care made inside prison and jail walls have an impact on the community at large.

This article will provide you with the ingredients successful public health and correctional collaborations related to HIV care, and suggestions on the types of programs that might be implemented in correctional settings, as described by the speakers at both conferences. In the new millennium, the solution to providing improved correctional health care while retaining control of the correctional budget may well be to create links between correctional health care and public health programs.

HIV Testing

Public health HIV testing programs exist in every state. The tests are offered at local departments of health, local clinics, health care vans, and substance abuse centers through funding by departments of health. In the past, correctional systems have been able to take advantage of partnerships with state and city departments of health to perform HIV testing in correctional settings; in some cases, public health workers may be recruited to perform HIV pre-counseling and screening at intake.

Correctional systems should contact their state departments of health to inquire whether the DOH is willing to support the cost of HIV testing at intake, at least in part, or perform the HIV test at a discounted rate (compared to commercial laboratories).

HIV Treatment

In the pre-managed care era, some state departments of health were responsible for providing HIV care to jails and prisons. In some states, this model still exists, while in others, DOH activities have shifted.

In Rhode Island for example, the existing HIV care program was initiated as a RI State Department of Health project. The department of health shifted its funding support from treatment to prevention, as the Rhode Island Department of Corrections assumed fiscal responsibilities for the treatment of the incarcerated. At present, the Rhode Island DOH supports activities associated with case management of HIV positive inmates as well as various peer education and prevention activities within the ACI. For more information on Rhode Island's case management and peer education pro- grams, contact Lucille Minuto, Assistant Administrator or Paul Loberti, Chief Administrator, Office of HIV & AIDS at the Rhode Island Department of Health at 401.222.2320.

HIV Transitional Case Management

Transitional case management is an important component of discharge planning. It involves visits to correctional facilities by community-based case managers who assist inmates with planning for care after release and provide a support network for the patient after his or her return to the community.

The State’s Health Resources and Services Administration, an agency of the Department of Health and Human Services, administers the Ryan White CARE (Comprehensive AIDS Resources Emergency) Act through its HIV/AIDS Bureau. The CARE Act was named in honor of Ryan White, a young Indiana teenager who died from AIDS in 1990. The CARE Act funds primary health care and support services for low-income, uninsured and underinsured individuals and families affected by HIV/AIDS.

These funds are distributed to states, U.S. territories and major metropolitan areas; local planning bodies then determine funding based upon priorities within the community. CARE Act funds do not support the provision of care in correctional facilities (such as that normally provided by nurses and doctors working with HIV patients). However, community based organizations who receive Ryan White funding have provided transitional case management in correctional facilities (see Table 1).

Funds are available for HIV case management and discharge planning correctional institutions through the Special Projects of National Significance (SPNS) Program, which supports innovative models of HIV/AIDS care for medically under-served and hard-to-reach populations. In 1999, seven states received funds from SPNS and the Centers for Disease Control to improve continuity of HIV care once individuals are released from correctional facilities.

For more information on CARE Act programs, contact your local health department or Barbara Aranda-Naranjo, PhD, RN, FAAN, Director of the SPNS Program, at 301.443.9976. (HRSA's website is www.hrsa.gov/hab). The most successful discharge planning programs invite community-based HIV care providers to come into the jail or prison and arrange for the patient's follow up at the clinic in the community.

HIV Discharge Medications

Traditionally, correctional systems provide a supply of medications to inmates upon release. The amount of medications supplied is usually linked to the expected delay between release and re-entry into the community HIV care system, a duration that may be shortened by providing links to publicly funded ADAP (AIDS drug assistance programs) at the time of release. See Table 2 for a listing of ADAP contacts in high HIV prevalence states (contact HIV/AIDS Bureau at HRSA at 301.443.6745).

One option for correctional HIV providers is to fill out the ADAP paperwork and obtain ADAP approval prior to release. The inmate is then given a contact for the ADAP program at the time of release and medications can start as soon as he or she selects a pharmacy. An additional "bridge" for the inmate who is to be released on medications is now provided by Stadtlanders, one of the major pharmaceutical contractors to correctional facilities. Stadtlanders has developed a free program for discharge medications called "StadtRelease" (contact Kimberly Betty at 800.833.2510 x31458 or visit the Corrections Health Care Network archives at www.corrections.com/health/healtharchives.html for more information).

TB and STD Treatment

Public health programs have consistently been involved in the diagnosis and treatment of STDs and TB in correctional settings. The list of correctional systems with access to DOH assistance for these diseases is too long to publish in this space, but would serve as an indicator of DOH willingness to support programs addressing the diagnosis and treatment of diseases that are considered a "public health concern." It may indeed be possible to build on existing models of STD/TB collaborations to increase public health programmatic support of HIV diagnosis and management in correctional settings.

HIV Education Programs

Free educational material and on-site programs for care providers, patients, and correctional staff are available through a wide variety of publicly funded resources:

1. HIV Education for Providers
   
   

• AETC: Federally supported AIDS Education and Training Centers (funded through the Department of HHS) have recently shifted their focus to address the needs of correctional HIV providers (http://www.hrsd.dhhs.gov).

• HHS: Additional free HIV treatment resources include the HHS guidelines for the management of HIV, opportunistic infection, which are published on the web (http://hivatis.org/trtgdlns.html) and updated yearly by a national panel of experts. (see page 7, HIV 101).

• Publications: The Johns Hopkins HIV report, HIV Insite (from the University of California at San Francisco) and the JAMA HIV website (http://www.hopkins-aids.edu/, http://hivinsite.ucsf.edu, http://www.ama-assn.org/special/hiv/hivhome.htm) are additional free resources that can be accessed by correctional HIV providers.

• HEPP News: This monthly newsletter is available at no cost to correctional HIV providers (fax-back form on page 7; website http://www.corrections.org). HIV Inside, another quarterly publication, is available by request from World Health Communications (see page 8). Both publications provide Continuing Medical Education credit (CME) for providers. CEU for pharmacists and nurses will be available later this year.

2. HIV Education for Patients
   
   

• Ryan White: Fortunately, patient education-and specifically education by peers-is a primary focus for public health funding. Both federal and local programs are accessible to correctional HIV providers. The best contact for information would be the Ryan White Committee (through your local health department). They will provide a list of community based organizations that are willing to come to your facility to facilitate educational programs for inmates.

• Other HIV Education Programs: A number of model programs such as ACE (Bedford Hills, NY), Span (Massachusetts), and Centerforce (San Quentin, California) successfully met inmate HIV educational needs. Some of these programs have recently demonstrated the positive effects of HIV education on subsequent HIV risk behavior after release.²

3. HIV Education for Staff
   
   

• Correctional security staff are the "third partner" in correctional HIV care, since they control the flow of inmates to medlines and clinics. In a number of states, AETC-funded programs that have provided education to correctional security staff have been well-received (see Table 1.) Several pharmaceutical companies are also developing free programs in recognition of the important role that correctional officers play in patient care.

Summary

Correctional interventions in the area of HIV care have had a dramatic impact in the last decade, mainly due to the identification and treatment of HIV infected individuals who were unaware of their infection prior to incarceration.^{3 4 5} Correctional settings can be where persons at risk learn about HIV, about how to avoid HIV infection and become informed consumers, learning how to manage their disease. However, advances in HIV treatment in correctional settings have been uneven at best. Poor correctional HIV management can have an adverse impact on public health. Spotty medication delivery, inattentive prescribing of HIV medications, and failure to provide adequate prophylaxis can result in the delivery of inmates who are sicker and more likely to be infected with drug resistant strains of HIV back to their communities. For an even more inspirational view of our role as providers at the nexus of public health, read Dr. Newton Kendig's plenary speech, in this issue of HEPP News on page 4.

Table 1:
Examples of some successful public health/corrections collaborations

Table 2: Ryan White/ADAP Contact Information

References

*Speaker’s Bureau: Abbott Laboratories, Glaxo Wellcome and Merck & Co.

**Speaker’s Bureau: Agouron Pharmaceuticals, Bristol-Myers Squibb, DuPont, Glaxo Wellcome, Merck, Roche.

1. Pharmaceutical companies have also recognized the importance of public health- corrections linkages and were instrumental in providing support for these two conferences: HIV/AIDS Behind Bars at the Florida NCCHC was supported by an unrestricted grant from Glaxo-Wellcome. Public/Health Corrections collaborations was supported by an unrestricted grant from Briston-Myers Squibb. Integrating Public Health and Corrections Collaborations was supported by an unrestricted grant from Bristol Meyers Squibb, with additional support from the CDC, the City of Chicago Public Health, the Health Resources and Services Administration, the National Institute of Justice, Substance Abuse and Mental Health Services Administration, and in kind contribution from the National Commission on Correctional Health Care.

2. Grinstead, O., Zack, B., Faigeles, B. "Collaborative research to prevent HIV among male prison inmates and their female partners.", Health Education Behavior 1999 Apr;26(2):225-38

3. Mostashari F, Riley E, Selwyn A, Altice F. "Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility." J Acquir Immune Defic Syndr Hum Retrovirol 1998 Aug 1;18(4):341-8

4. Hammett, T. M. Prevention and Treatment of HIV/AIDS: An opportunity not yet seized. HEPP News, December 1999; 2(11).

5. Maruschak, L. (1999), HIV in Prisons 1997, Bureau of Justice Statistics Bulletin, U.S. Department of Justice, Washington DC, November 1998.

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©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.

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