hiv and incarceration: dual epidemics€¦ · • 1,301 without a prior hiv diagnosis – 38...
TRANSCRIPT
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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
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• 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