SPNS Initiative: Findings From The Field
SPNS Initiative: Findings From The Field
EnhanceLink staff “understand. They don’t judge you. My family judged me right away. They would help me one week and if I relapsed well, ‘The hell with you. I’m tired with you. You’re never going to change…’ See with [EnhanceLink] there is hope. They see potential in me…. [They ask] ‘What do you need?’ Nobody’s ever asked me that! And it’s programs like this that help me get through life.”*
— EnhanceLink Participant
The EnhanceLink project was funded to design, implement, and evaluate innovative methods for linking people living with HIV/AIDS who are in jail settings—or who have been recently released from local jail facilities—into HIV primary medical care and ancillary services. The project was based upon the Framework for Program Evaluation in Public Health28 as well as the Behavioral Model for Vulnerable Populations, which asserts that predisposing and need factors as well as enabling resources all influence health behaviors and, in turn, health outcomes.29
Overall, EnhanceLink conducted and enrolled the following:
- HIV tests. During 877,119 admission events there were 499,131 HIV tests offered with 210,267 inmates agreeing to test.
- New HIV diagnoses. Of the 1,312 positive HIV tests, 822 represented newly diagnosed individuals.
- Participants. In total, 1,270 HIV-positive participants enrolled in the EnhanceLink study; most were previously diagnosed and out of care.30 To avoid any sense of coercion, individuals could still receive linkage services even if they declined to formally enroll in the study. At a minimum, all sites followed participants for 6 months post-release, although some grantee sites followed jail inmates upon release for longer.20,31
Among EnhanceLink participants, less than one-half had a high school diploma or GED and median lifetime arrests were 15.32 Among previously diagnosed participants, 90 percent had known their HIV status for more than 2 years, and 81 percent had never taken ART medications.32
Many participants in the study reported past diagnoses of STIs. Hepatitis C was the most common HIV coinfection. In addition, many EnhanceLink participants had histories of depression, and suicidal ideation and attempts; other kinds of emotional distress were also prominent. Only a few participants had a formal mental health diagnosis, despite 54 percent presenting with an Addiction Severity Index (ASI)33 mental health score of .22 or greater, indicative of severe psychiatric illness.3,34 Nearly all participants had histories of substance use; 59 percent had ASI drug scores of at least .16, which represents severe drug addiction.3
Seventy percent of participants were male with an average age of 42 years. Viral load and CD4 counts revealed that 66 percent of participants had uncontrolled viremia (viral load > 400 copies/ml).30
While Blacks represent 46 percent of HIV-positive persons and 40 percent of the incarcerated community, the numbers were even higher among EnhanceLink participants: 65 percent were Black.32 Black EnhanceLink participants were less likely than other participants to have health insurance upon entering jail, reflecting health inequities that exist within jail subsets, particularly by race.32 Black EnhanceLink participants were also the most likely to identify as homosexual or bisexual, and to have advanced HIV disease.32
“Without treatment or consistent care, chronic conditions worsen until individuals are forced to present to emergency rooms for care, ratcheting up costs to the health care system. With proper continuity of care resources in place, much of this cost can be avoided.”
— Hannah Zellman, Philadelphia FIGHT, EnhanceLink grantee
Source: Zellman H. Philadelphia Fight Institute for Community Justice. Establishing the need for an intervention program. 2012. [unpublished]
EnhanceLink Participating Sites
- AID Atlanta, Inc.
- Care Alliance Health Center
- AIDS Care Group
- Yale University AIDS Program
- University of Chicago, IL School of Public Health
- Baystate Medical Center, Inc.
- University of South Carolina Research Foundation
- Philadelphia FIGHT
- NYC Department of Health and Mental Hygiene
- Miriam Hospital
Evaluation Center: Emory University Rollins School of Public Health and ABT Associates were subcontractors.
Source: de Voux A, Spaulding AC, Beckwith C, et al. Early identification of HIV: empirical support for jail-based screening. PLos One. 012;7(5):1–7.
Women in Jail
Approximately 12 percent of total jail detainees in the United States are women, a number that’s grown fivefold since 1985. Incarcerated women often have histories of childhood sexual abuse and neglect, sex work, and intimate partner violence (IPV). HIV-positive women in the EnhanceLink study suffered greater burden of illness, and were more likely to be homeless, less adherent to ART, and had more severe addiction issues. To be most effective, interventions should reflect gender-specific differences and women’s experiences of HIV and incarceration.
Sources: Minton TD. Department of Justice. Jail inmates at midyear 2010. Washington, DC.
University of Illinois at Chicago, Community Outreach Intervention Projects, School of Public Health. Enhancing linkages to care for women leaving jail. Final report. 2012. [unpublished.]
Dwyer M, Fish DG, Gallucci AV, et al. HIV care in correctional settings. Guide for HIV/AIDS Clinical Care. HRSA, HAB. June 2012.
Tinsley M. HRSA, HAB, SPNS Program. Enhancing linkages to primary care & services in jail settings: a critical HIV/AIDS Bureau initiative. [Presentation.]
Meyer JP, Zelenev A, Wickersham J, et al. Women released from jail experience suboptimal HIV treatment outcomes compared to men: results from a multi-center study. [unpublished]
*Nunn A, Cornwall A, Fu J, et al. Linking HIV-positive jail inmates to treatment, care, and social services after release: results from a qualitative assessment of the COMPASS Program. Journal of Urban Health. 2010;87(6):954–68.
The EnhanceLink interventions were deemed cost-effective from a societal perspective with an average cost per client linked at $4,219; the mean cost per 6-month sustained linkage was $4,670.23
Having a case manager work closely with the jail medical staff may reduce costs incurred by the jail, which could be motivation and justification for establishing such a partnership. Cost-cutting is a big selling point in establishing partnerships between communitybased organizations, jails, and health departments. For example, the case manager at the University of South Carolina Research Foundation project worked to obtain medical records from community clinicians, thus reducing duplications in lab work and diagnostic evaluations.
Of those previously diagnosed, only 55 percent were on HIV medication leading up to 7 days before incarceration.10 As the EnhanceLink Evaluation Center summarized, “Jails therefore serve as an opportunity to re-start ART among those who have fallen out of care or some who had discontinued ART due to substance use.”10
The EnhanceLink project did not identify a substantial increase in pharmacy costs with many detainees initiating ART post-release given their short stay.10 If a person was pre-trial, some case managers were able to negotiate to have their home HIV medications be given in the jail. This approach was so successful that after completion of the SPNS grant, the jail created a case manager position to continue the effort.34 Another grantee—the NYC Department of Health and Mental Hygiene—was able to direct some of their Ryan White Part A Early Intervention Services funding toward sustaining their jail linkage efforts at Riker’s Island.35
Another cost-effective intervention involved coordination of medical records. In response to a jail medical director’s capacity to treat HIV-positive inmates, one grantee site examined their patient immunology charts. If the inmate had been seen at the community clinic previously, the community HIV doctor would engage in a case conference about the patient with the jail medical director. “This enhancement improved the quality of medical care provided to the HIV positive inmates, while stretching dollars for the facility. This is a costeffective method in which to provide specialty care in collaboration with the medical team at the jail.”34
Findings from EnhanceLink were consistent with the Antiretroviral Treatment and Access Study (ARTAS), supporting the role of case management. Both found that people who participated in case management were more likely to follow up on care referrals.29 Coordinating social services was associated with retention in care;36 one EnhanceLink site found a ninefold increase in retention in care when patients were linked to a Ryan White medical case manager in the community at time of release.37
EnhanceLink interventions are beyond the services typically offered within a jail setting. The project illustrates that jail inmates can benefit from these services, and individual morbidity and mortality are reduced.38 Medical treatment adherence increased when HIV detainees were immediately linked to primary care while receiving continuous case management and support services to address their particular psychosocial needs.40
Study participants noted that EnhanceLink helped prevent relapse and promoted adherence to ART.3 This is important, since participants with pre-incarceration heroin and cocaine use were more likely to relapse after release, underscoring that addiction is a chronic, relapsing disorder and that linkage programs must take substance use into account when creating linkage and care services.39
Grantees found that they could improve health care outcomes and recidivism by addressing—through the inclusion of substance abuse treatment, intensive psychosocial support, prevention education, and self-esteem building—underlying factors that cause people to fall out of care and become repeat offenders.40 For example, individuals receiving community-based services within 30 days of release were more likely to be engaged in HIV primary care. Those released with stable housing were also more likely to be linked to care,41 as housing has been tied to a more stabilized lifestyle, reduction in drug use, and increased health care utilization.3
Treatment adherence is associated with reduction in recidivism,42 improved health behaviors, and enhanced secondary HIV prevention.3 Significant factors associated with decreased patient viral load include attending the first case manager meeting, assessing patient needs for HIV-related medical services, having health insurance at time of incarceration, and having a copy of one’s medical record at time of release. Not surprisingly, the number one predictor of success was attending a meeting with one’s HIV care provider within 30 days of release.38
Overall, the patients in the EnhanceLink study achieved clinical care engagement rates comparable to those in other clinical settings. This is important to underscore, given the transient nature of jails, and the high rates of psychosocial issues among those released from jail.38 Participants would recommend the program to others and credit it with successful transition back into the community.40
Before You Get Started: Laying the Groundwork
Before community-based organizations get started on this work, it is important to examine existing programs and other organizations operating within the jail in order to avoid duplication of effort or starting an intervention program without the capacity to complete it. For program evaluation, it is also important to pre-determine how to collect and store data, how data will be analyzed, and questions to be documented and answered.36 Prior to outlining project specifics, it is imperative to understand the culture of corrections, what may or may not be permissible within these environments, and implications to your proposed program.
Jails have close proximity to their surrounding communities and can vary dramatically in size and scale, from small county lockups to large city jail facilities. Policies can also vary by facility, region, and State. The practices outlined in this training manual and its associated implementation and pocket guides may need to be modified based on the regulations applicable within your specific jail setting.
A single city or county typically operates a jail and most receive little or no supplemental support from State or Federal funding to expand services beyond their critical core mission of promoting public safety.23 Motivation for jail administration to participate in public health interventions comes from informed jail leaders, a demonstration of cost-effectiveness and value to society, and the development of a trusting collaboration with a community health partner.23 It is also helpful to plan your intervention through the “eyes of the jail administrator” and anticipate any concerns related to implementation—such as security, space or costs—and address those concerns up front.”43
It is important to recognize that inmates may distrust clinical care providers due to poor experiences in the past, or attitudes of fatalism;34 racial, ethnic, and class differences between inmates and corrections staff can add to this distrust. Effectively working within the jail thus requires a high degree of cultural competency. Minimizing staff turnover will help maintain continuity of relationships with inmates and newly released individuals. As one grantee summarized, “None of this can be accomplished without the central goal of developing trust and rapport with the client—no small feat in a jail environment that often feels unsafe, especially for individuals living with HIV.”43
It is difficult to adhere to Health Insurance Portability and Accountability Act (HIPAA) regulations to offer privacy and confidentiality when working with inmates. In addition, State-specific statutes may apply to HIV matters of confidentiality. Additional steps may be necessary to safeguard HIV status, and community-based health providers should discuss this issue with jail administrators.43 Providers should also clarify with inmates how their health information may be used, as well as how it is being safeguarded.
Navigating through policies, and the administrative, procedural, organizational, and security measures within a jail facility can be difficult and requires clear communication by all parties.5 Community-based organizations and health providers need to understand the jail environment in which they are working—one where safety and security are top priorities. This means that lockdowns may occur, and that community-based providers may not be allowed in on a given day; that some traditional supplies (e.g., paper clips or pens) may not be suitable or allowed in jail; that even cellphones may be considered contraband. In some settings, visitors are not permitted to bring anything with them into the jail setting, including food (although this varies from jail to jail), but, if permissible, food may encourage the development of relationships. As one grantee expressed, “Nothing brings people together like food,” and her organization as well as other grantees found providing food to jail staff to be a nice, nonthreatening way to foster good will.37,44
Any person entering a jail needs authorization from the jail to be admitted. However, hiring and clearance policies between the community-based provider and the jail could differ. A person who passes a background check with the community-based site may not necessarily be cleared to work in the jail. A system should be established between the jail, corrections administrator, jail health provider, and community partners for identifying and assessing eligible patients, communicating regularly, pre-release planning, and sharing health information in ways that ensure HIV confidentiality.45
As you develop your program, and determine its scope and the requisite steps for implementation, also focus on protocols, processes, and procedures, and obtain feedback while the program or intervention is being implemented. The scope and range of services offered inside jails should be individualized to fit the needs of inmates who require a range of medical and mental health care and social support. No “one-size-fits-all” model will work for patients or programs, and some adaptability may be necessary. However, specific interventions planned to outside groups must receive approval from jail administration, and this may limit the range of intervention available. However, a record of community groups being allowed access to inmates within jails for purpose of conducting an intervention may eliminate the need for outside groups to “prove themselves” before an expanded range of interventions is permitted.46
Securing Buy-in and Creating Partnerships
In building relationships with corrections staff, community-based providers should engage the entire staff (e.g., medical staff, warden, corrections officers). Given the hierarchical structure of jails, it is effective to first target high-level decision makers in proposing intervention. Senior leadership at meetings will increase the likelihood for success.47
In some cases, jail officials who are not part of the medical staff may seek to learn the HIV status of inmates. Protecting patient confidentiality is of utmost importance, and education sessions with corrections administrators about HIV will help enforce this.48 These sessions can address misconceptions, provide information about transmission, explain post-exposure prophylaxis policies, and underscore the importance of patient confidentiality.43,64 By educating county probation and parole staff about your project and goals, you will improve communication, which may also enhance patient followup.31,43 High staff turnover within correctional settings may necessitate the frequent jail staff trainings.43 Similarly, community-based providers will benefit from security orientation sessions by corrections administrators.31
Collaboration and coordination with outside agencies may be necessary, and finding key supporters will help you spread the word. Opinion leaders in the community may be Ryan White Planning Council, consortia, or consumer advisory board members. Involving them in early discussions will improve programming and help you gain buy-in. In facilities both large and small, local health departments can often provide support as well.20
Sharing information and goals up front enhances partnerships by allowing all parties to have a voice. For more formal partnerships, memorandums of understanding (MOUs, for both community-based organizations and jail facilities) will facilitate documenting services, relationships, and reportorial structures. Teambuilding activities may also be useful, especially those that involve the development of universal forms that can be shared by jail and community providers to streamline enrollment and reduce duplication of efforts.5
EnhanceLink grantees underscored, however, that an MOU must be backed by support; sincere buy-in from collaborating partners and community stakeholders is essential. As one grantee explains, “People think you get an MOU and that’s it, but it’s not it. It’s just the beginning.” 49 For some EnhanceLink sites, the research grant functioned as a kind of MOU, where partner roles were outlined in the grant application itself. MOUs can be helpful in jumpstarting communication but ongoing conversation and collaboration are necessary.
Sites tailored their linkage programs to their communities and the jail settings with whom they partnered. For grantees with a strong safety net of community services, the majority of their activity was focused on work within the jail, while providers with less developed referral networks allocated more time to the post-release phase.23 Multiple sites found it helpful to have the case manager position split their time between the jail and the community as a way to better nurture community partnerships and connect patients to services postrelease. Success in jails for community-based providers requires their flexibility and adaptability.