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

12/13/19 Expanding HIV Testing, Prevention and Treatment in Jail Are we equipped to traverse “the last mile”? A Asa Clemenzi-Allen, MD, MAS 1 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) program 2 1

12/13/19 Disclosures • No Potential Conflicts of Interest to Disclosure 3 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) 4 2

12/13/19 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 5 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? 6 3

12/13/19 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 7 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? 8 4

12/13/19 Promoting Linkage to Testing and Care Opportunities for Pre-Incarceration Post-release testing and linkage Disengagement Engagement to treatment and from Care in Care prevention services 9 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 10 5

12/13/19 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 11 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 ) 12 6

12/13/19 At-Risk for HIV, Disengagement from Care Substance Use Disorder Homelessness/ Racial/Ethnic Unstable Minority Housing Psychiatric Disease 13 At-Risk for HIV, Disengagement from Care 56% - history of substance use Substance Use disorder Disorder 32% - under the influence of an illegal drug at the time of arrest Homelessness/ 47% - non-latinx white Racial/Ethnic Unstable Minority 40% - experience homelessness Housing 2% - percent of total population Psychiatric living with HIV who experience homelessness and incarceration Disease 20% with serious mental illness Westergaard et al 2013 Curr Opin Infect Dis; Prins et al 2015 Psych Serv 14 7

12/13/19 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 15 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 16 8

12/13/19 Gaps in HIV Testing in U.S. Jails of Jails nationally confirm to best practice HIV testing policies provide testing services have opt-out testing Solomon et al 2014 Health Aff 17 Gaps in HIV Treatment in U.S. Jails offered ART provide recommended discharge planning services provide only passive referral Solomon et al 2014 Health Aff 18 9

12/13/19 Interventions to Address Current Gaps 19 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 20 10

12/13/19 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 ) 21 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 ) 22 11

12/13/19 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 ) 23 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 ) 24 12

12/13/19 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) 25 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 26 13