HIV and Incarceration: Dual Epidemics€¦ · • 1,301 without a prior HIV diagnosis – 38...

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HIV and Incarceration: Dual Epidemics David A. Wohl, MD Site Leader. UNC AIDS Clinical Trials Unit at Chapel Hill Co - Director of HIV Services for NC Department of Public Safety

Transcript of HIV and Incarceration: Dual Epidemics€¦ · • 1,301 without a prior HIV diagnosis – 38...

Page 1: HIV and Incarceration: Dual Epidemics€¦ · • 1,301 without a prior HIV diagnosis – 38 refused testing and/or a baseline specimen was not available for confirmatory testing

HIVandIncarceration:DualEpidemics

DavidA.Wohl,MDSiteLeader.UNCAIDSClinicalTrialsUnitatChapelHillCo-DirectorofHIVServicesforNCDepartmentofPublicSafety

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TakeHomes• IncarcerationintheUSisepidemic anddestructiveonmultiplelevels:– Individual– Community– Societal

• Theepidemics ofHIVandincarcerationoverlap,promoting:– Transmissionincommunitiesaffectedbyboth– Heavyburdenofdiseaseamongprisoners

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Questionforyou:

TherateofprisonorjailincarcerationamongadultsintheUSis:

§ 1in100§ 1in500§ 1in1000

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Questionforyou:

TherateofprisonorjailincarcerationamongadultsintheUSis:

§ 1in100§ 1in500§ 1in1000

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1in99adultsinUSareincarcerated1in31areincarceratedorundersupervision

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$

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Stateswithrestrictionsonvotingbasedoncriminaljusticerecord

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Gender ratios by race/ethnicity

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CONTEXT-NETWORK RELATIONSHIPS

Adimora VJ, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. JID 2005:191:S115

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Mental Illness/Substan

ce Abuse

PovertyInternet?

Incarceration

TheFourHorsemenoftheModernDomesticHIVEpidemic

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Rethinking the Role of Incarceration in the HIV Epidemic

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Rethinking the Role of Incarceration in the HIV Epidemic

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Each year:

14% of all people in the US with HIV

33% of those with HCV

40% of those with Tuberculosis

pass through correctional facilities.Source: Spaulding et al. (2009); Hammett, Harmon, & Rhodes (2002). AJPH, 92 (11), 1789-1794.

InfectiousDiseasesintheCorrectionalSystem27

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BJSReport2015Atendof2010:• Over20,000peopleinfederalandstateprisonswereknown

tobeHIV+(146per10,000)• NumberofinmateswithHIVinfectiontrendingdown.• Ratesofdeathamongprisonersdeclining.

http://www.bjs.gov/index.cfm?ty=pbdetail&iid=4452

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Results: < 400 c/mL (ITT)Median time observed on therapy 26 weeks (IQR: 12, 70)

l Virologic failure(HIVRNA>400c/mL)at6- 12months:25.5%

Wohl D et al, IAS 2008ARTSUCCESSINPRISON

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Accessing HIV Meds after Prison Release

• Review of ADAP Rx records in Texas 2004-2007

• N=2115 receiving ART at release

– 83% male– 60% African-American– 18% with mental health d/o– 53% incarcerated >1 year– 95% released to metro areas

• Associated with filling RX: Non-white, undetectable VL, parole, received pre-release assistance with ADAP application

Baillargeon J, et al. JAMA 2009

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SPECTRUMOFCAREENGAGEMENT

IsincarcerationanopportunitytodetectHIV?

HowcansuppressionofHIVbemaintainedafterrelease?

WhatistheHIVcascadeinprison?

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SCREENStudy(NIMHR01MH079720)

WohlD,Golin C,RosenD,etalCROI2013

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WohlD,Golin C,RosenD,etal.JAMA2013

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AnRCTofanaugmentedtest,treat,link,&retainmodelforNCandTXHIV+prisoners(NIDAR01DA030793)

• Sites– TwoStatePrisonSystems:– TexasDepartmentofCriminalJustice(TDCJ)– NorthCarolinaDepartmentofPublicSafety(NCDPS)

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Viral Load Assessment

Enroll

=PrisonRelease =FacetoFaceMIwithCognitiveMapping

=TelephoneMI=dailytextremindersbeforeARTdosing

Link Coordinator Needs

Assessment

Study Week

Connect to Clinic

-12 -4 0 2 4 6 8 10 12 14 16 18 20 22 24

1:1Randomizationtostandardofcarevs imPACT

imPACT Intervention

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PercentwithSuppressedHIVRNAPost-Release–CombinedStudyArms

0

10

20

30

40

50

60

70

80

90

100

Week2 Week6 Week14 Week24

%HIVRNA<40c/mLAFTERrelease

N=310 289 257 211

MedianHIVRNAlevelamongthosewithdetectable level*

Week 2 5,363c/mL

Week6 19,467c/mL

Week14 24,859c/mL

Week24 22,641c/mL*>20c/mL

Dataarepreliminary andsubject tochangewithfurtheranalysis

74%Non-white21%Female7%Hispanic

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Results:EffectonWeek6ClinicVisits

86%

67%75%

66%

0%10%20%30%40%50%60%70%80%90%100%

Allnon-emergencyvisits

HIVCarevisits

imPACT

Control

*138

122

107108

*P<0.02

Themediantimetofirstmedicalclinicappointmentfollowingreleasewas10daysforimPACTversus13daysforcontrols(P=0.03).

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Results:EffectonViralSuppression

0.93

0.810.78

0.71

0.60

0.85

0.740.68

0.63 0.61

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

-12 0 2 6 14 24

Pro

port

ion

of p

artic

ipan

ts w

ith H

IV R

NA

<50

cop

ies/

ml

(for

bas

elin

e [-

12 w

eeks

] <75

cop

ies/

ml)

Study week (prison release=0)

A) Multiple Imputation

Intervention

StandardCare

Number of participants contributing data Intervention 195 195 195 195 195 Control 186 186 186 186 186 P-value 0.21 0.12 0.05 0.18 0.84

0.93

0.83 0.81

0.73

0.62

0.85

0.750.69

0.65 0.63

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

-12 0 2 6 14 24

Pro

po

rtio

n o

f p

arti

cip

ants

wit

h H

IV R

NA

<50

co

pie

s/m

l(f

or

bas

elin

e [-

12 w

eeks

] <7

5 co

pie

s/m

l)

Study week (prison release=0)

B) Complete Case

Intervention

StandardCare

Number of participants contributing data Intervention 195 155 146 132 128 Control 186 153 143 140 125 P-value 0.21 0.06 0.02 0.13 0.81

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80%ofparticipants(n=321)hadnon-emergentclinicvisitbyweek6Post-Release

%Self-Reporting HIVcommunityclinicvisit

%Self-Reporting othercommunityclinicvisit*

66% 24%*Excludesemergentcare

0

10

20

30

40

50

60

70

80

90

100

Control imPACT

Control

imPACT

Anynon-emergentclinicvisitbystudyarm

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HPTN061– DeservesMention

Brewer R, et al AIDS 2012

Page 42: HIV and Incarceration: Dual Epidemics€¦ · • 1,301 without a prior HIV diagnosis – 38 refused testing and/or a baseline specimen was not available for confirmatory testing

• 1,553menwereenrolled– 252reportedapriorHIVdiagnosis

• 1,301withoutapriorHIVdiagnosis– 38refusedtestingand/orabaselinespecimenwasnotavailableforconfirmatorytestingattheHPTN

• 1,263underwentHIVtesting• 96werenewlydiagnosed,including3withacuteinfection(identifiedbytheHPTN)– 1,167uninfectedatbaseline– 1,009testedforHIVduringstudyfollow-up

• 28(3%)becameHIVinfected

Studypopulation

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60%hadhistoryofincarceration

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Women,% Men,%

DisclosureofSexualPreferenceDuringIncarceration

Rosen DL, Schoenbach VJ, Wohl DA, White BL, Stewart PW, Golin CE. Am J Public Health. Oct 2009

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Gallup

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Whatweshoulddo§ Recognizethetoxiceffectsofmassiveincarceration§ Takeadvantageoftheopportunitypresentedby

incarceration/supervision toapplyseek-test-counsel-support-treat-engage indurablecare

§ DemonstrateandadvocateforimplementationofevidencebasedinterventionsinCJsettings

§ Explorefurtherthecollateraldamageofincarcerationoncommunities

§ ExaminetheimpactofchangesinepidemiologyofHIVandUShealthcarepolicyonHIVandHCVinCJsettings

§ Advocateforchange toreininthissociallydisruptiveforce

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The Continuum Challenge

Arewedoingthebestwecan?§ Diagnosis

– Infectiousdiseases (HIV,STI,TB,HCV,HBV)

– MentalIllness– Substanceabuse

§ Treatment§ Linkagetocommunitycare

How do we maintain the benefits of care experienced during incarceration?§Linkage to care and services§Adequate community resources

§Treatment (HIV, mental health, substance abuse)

Howtobreakthecycle?§Societalchallenge(Poverty,discrimination, sentencinglaws)§Policy

Incarceration Freedom

Reincarceration

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CathieFogelCarolGolinBeckyWhiteDavidRosenMariaKhanClaireFarelJessicaCarda

CatherineGrodenskySharonParkerMichaelBowlingRobertDeVellisMeheret MamoLynn Tillery

Makisha RuffinGenda DockeryShirley BrownKarishma Oza

KathrynMuessigChaunetta JonesSteveBradley-Bull

Kemi AmolaLisaMcKeithanNeeve Neevel

MadelineMcCraryKimPowersPaulaSmithPamGibbs

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Discussion


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